Blood kinetics of ethyl glucuronide and ethyl sulphate in heavy drinkers during alcohol detoxification

Brief history of the alcohol biomarkers CDT, EtG, EtS, 5-HTOL, and PEth

This article traces the historical development of various biomarkers of acute and/or chronic alcohol consumption. Much of the research in this domain of clinical and laboratory medicine arose from clinics and laboratories in Sweden, as exemplified by carbohydrate deficient transferrin (CDT) and phosphatidylethanol (PEth). Extensive studies of other alcohol biomarkers, such as ethyl glucuronide (EtG), ethyl sulfate (EtS), and 5-hydroxytryptophol (5-HTOL), also derive from Sweden. The most obvious test of recent drinking is identification of ethanol in a sample of the person's blood, breath, or urine. However, because of continuous metabolism in the liver, ethanol is eliminated from the blood at a rate of 0.15 g/L/h (range 0.1-0.3 g/L/h), so obtaining positive results is not always possible. The widow of detection is increased by analysis of ethanol's non-oxidative metabolites (EtG and EtS), which are more slowly eliminated from the bloodstream. Likewise, an elevated ratio of serotonin metabolites in urine (5-HTOL/5-HIAA) can help to disclose recent drinking after ethanol is no longer measurable in body fluids. A highly specific biomarker of hazardous drinking is CDT, a serum glycoprotein (transferrin), with a deficiency in its N-linked glycosylation. Another widely acclaimed biomarker is PEth, an abnormal phospholipid synthesized in cell membranes when people drink excessively, having a long elimination half-life (median ~6 days) during abstinence. Research on the subject of alcohol biomarkers has increased appreciably and is now an important area of drug testing and analysis.

Confounders of Serum Phosphatidylethanol: Role of Red Blood Cell Turnover and Cirrhosis

Purpose

Ethyl glucuronide (EtG), ethyl sulfate (EtS) and phosphatidylethanol (PEth) are considered specific direct biomarkers for detecting alcohol consumption. However, PEth, which is produced in red blood cells (RBC), varies considerably between patients for unknown reasons. We here studied various confounders of PEth elimination including fibrosis after alcohol withdrawal.

Patients and Methods

EtG, EtS and PEth together with routine laboratory and clinical parameters were studied in 100 Caucasian heavy drinkers prior and after alcohol detoxification. In addition, fibrosis stage and degree of steatosis were assessed by transient elastography (Fibroscan, Echosens, Paris).

Results

All three biomarkers were highly correlated (0.61-0.72) with initial serum alcohol levels, but only PEth correlated with daily alcohol consumption. After alcohol withdrawal, PEth significantly decreased within 6.1 days from 1708 to 810 ng/mL (half-life varied from 1.6 to 15.2 days). Both levels of serum alcohol but also EtG and EtS were higher in patients with liver cirrhosis as compared to patients without fibrosis despite comparable alcohol consumption suggesting a decreased alcohol elimination in patients with cirrhosis. PEth was also elevated in cirrhosis but not significantly. In contrast, PEth elimination rate was significantly higher in patients with enhanced RBC turnover and signs of alcohol-mediated hemolytic anemia with elevated ferritin, LDH and increased mean corpuscular volume (MCV).

Conclusion

We here demonstrate that alcohol elimination is decreased in patients with liver cirrhosis. In patients with cirrhosis, PEth levels are both affected in opposite directions by enhanced red blood cell turnover and elevated alcohol levels. Our data have important implications for the use and interpretation of PEth in the clinical setting.

Human metabolome variation along the upper intestinal tract

Most processing of the human diet occurs in the small intestine. Metabolites in the small intestine originate from host secretions, plus the ingested exposome1 and microbial transformations. Here we probe the spatiotemporal variation of upper intestinal luminal contents during routine daily digestion in 15 healthy male and female participants. For this, we use a non-invasive, ingestible sampling device to collect and analyse 274 intestinal samples and 60 corresponding stool homogenates by combining five mass spectrometry assays2,3 and 16S rRNA sequencing. We identify 1,909 metabolites, including sulfonolipids and fatty acid esters of hydroxy fatty acids (FAHFA) lipids. We observe that stool and intestinal metabolomes differ dramatically. Food metabolites display trends in dietary biomarkers, unexpected increases in dicarboxylic acids along the intestinal tract and a positive association between luminal keto acids and fruit intake. Diet-derived and microbially linked metabolites account for the largest inter-individual differences. Notably, two individuals who had taken antibiotics within 6 months before sampling show large variation in levels of bioactive FAHFAs and sulfonolipids and other microbially related metabolites. From inter-individual variation, we identify Blautia species as a candidate to be involved in FAHFA metabolism. In conclusion, non-invasive, in vivo sampling of the human small intestine and ascending colon under physiological conditions reveals links between diet, host and microbial metabolism.

EtG Quantification in Hair and Different Reference Cut-Offs in Relation to Various Pathologies: A Scoping Review

Ethyl glucuronide (EtG) is a non-volatile, non-oxidative, hydrophilic, and stable ethanol phase II metabolite. EtG is produced through ethanol glucuronidation by UDP-glucuronosyltransferase (UGT), a phase II enzyme. EtG can be extracted from different biological matrices, including keratin ones, such as hair or nails. The purpose of this scoping review is to describe the relationship between EtG levels in hair and some of the most common and frequent pathological conditions and verify whether different reference cut-offs in relation to various pathologies have been identified in the scientific literature. In fact, in-depth knowledge of the influence of pathologies, such as diabetes mellitus, hepatic and renal dysfunction, on EtG production and its storage in keratin matrices would allow a more appropriate interpretation of obtained data and rule out false positives or false negatives. This scoping review is based on bibliographic research carried out on PubMed regarding the quantification of EtG in hair of subjects affected by different pathological conditions. According to the scientific literature, the main and most common pathologies that can affect the concentration of EtG in hair are liver and kidney diseases and diabetes. The EtG quantification analytical data should be interpreted carefully as they may have a great impact in both forensic and clinical contexts.

Validation of serotonin transporter mRNA as a quantitative biomarker of heavy drinking and its comparison to ethyl glucuronide/ethyl sulfate: A randomized, double-blind, crossover trial

BACKGROUND

The serotonin transporter (SERT) mRNA was previously reported to be a quantitative and pathophysiology-based biomarker of heavy drinking in 5HTTLPR:LL genotype-carriers treated with ondansetron. Here, we validated the potential use of SERT mRNA for quantitative prediction of recent alcohol consumption (in the absence of treatment) and compared it with the known biomarkers ethyl glucuronide (EtG) and ethyl sulfate (EtS).

METHODS

Binge drinking men and women of European ancestry aged 21 to 65 years were enrolled in a 12-day, in-patient, randomized, double-blind, crossover study, where they were administered three beverage doses (placebo, 0.5 g/kg [0.4 g/kg] ethanol, and 1 g/kg [0.9 g/kg] ethanol for men [women]) individually in three 4-day periods (experiments), separated by minimum 7-day washout period. Diet, sleep, and physical activity were controlled throughout the inpatient experiments. Twenty-nine participants were randomized to receive beverage doses counterbalancing the sequence of treatment and gender within subgroups stratified by SERT genotypes 5HTTLPR:LL+rs25531:AA (LA LA ) versus 5HTTLPR:LS/SS. Peripheral venous blood was collected daily for (1) quantification of SERT mRNA (the primary outcome measure) using qRT-PCR and (2) plasma EtG and EtS levels using tandem mass-spectrometry.

RESULTS

The association between administered beverage dose and SERT mRNA from completers of at least one 4-day experiment (N = 18) assessed by a linear mixed model was not statistically significant. Significant positive associations were found with beverage dose and plasma EtG, EtS and EtG/EtS ratio (β = 5.8, SE = 1.2, p < 0.0001; β = 1.3, SE = 0.6, p = 0.023; and β = 3.0, SE = 0.7, p < 0.0001, respectively; the C-statistics for discriminating outcomes were 0.97, 0.8, and 0.92, respectively). Additionally, we observed a sequence effect with a greater placebo effect on SERT mRNA when it was administered during the first experiment (p = 0.0009), but not on EtG/EtS measures.

CONCLUSION

The findings do not validate the use of SERT as a biomarker of heavy drinking. Larger and more innovative studies addressing the effects of placebo, race, gender, and response to treatment with serotonergic agents are needed to fully assess the utility of SERT as a biomarker of heavy and binge drinking.

Frequency of postmortem ethanol formation in blood, urine and vitreous humor - Improving diagnostic accuracy with the use of ethylsulphate and putrefactive alcohols

PURPOSE

This study aimed to compare the frequency of postmortem ethanol formation in blood, urine and vitreous humor according to negative ethylsulphate (EtS) in blood or positive putrefactive alcohols (PA's) in either medium. Furthermore, it aimed to evaluate the interpretational value of calculated ethanol ratios in relation to EtS and PA results.

METHODS

Blood ethanol positive forensic cases were included; one dataset consisting of 2504 cases with EtS analysed in blood and another dataset with 8001 cases where PA's were analysed.

RESULTS

PA's were found in 24.4% of cases. EtS was negative in 15.3%, 9.4% and 7.4% of cases that were positive for ethanol in blood, urine and vitreous humor, respectively. In EtS negative cases, the concentrations of ethanol in blood, urine and vitreous humor were lower than 0.20 g/kg in 51.3%, 67.4% and 77.8%, respectively. It was 1.0 g/kg or higher in blood in 4.2% of cases. More EtS negative and PA positive cases were seen in central compared to peripheral blood. Ethanol ratios between urine or vitreous humor and blood were significantly lower in both EtS negative and PA positive cases, but large variations were observed.

CONCLUSION

EtS and PA analysis improve the diagnostic accuracy of ethanol in postmortem cases. Postmortem ethanol formation in vitreous humor and urine were both more frequent than expected and we recommend the analysis of ethanol primarily in peripheral blood if available.

Development and validation of an analytical method for the simultaneous determination of the alcohol biomarkers ethyl glucuronide, ethyl sulfate, N-acetyltaurine, and 16:0/18:1-phosphatidylethanol in human blood

As alcohol is the most common addictive substance worldwide, it is inevitable to advance the established research. New and more substantial analytical methods can be applied to reply to complex questions in legal or forensic contexts. Therefore, an analytical method for the simultaneous determination of four different alcohol biomarkers-ethyl glucuronide, ethyl sulfate, N-acetyltaurine, and 16:0/18:1-phosphatidylethanol-in human blood was developed, validated, and verified. Despite the different chemical properties of the analytes, a specific determination via HPLC-MS/MS was achieved using a novel type of a Phenomenex Luna® Omega Sugar column. Furthermore, all criteria for a successful validation were fulfilled according to forensic guidelines. The method proved to be linear and demonstrates selectivity and sufficient sensitivity for every biomarker. LODs obtained with this method of 2.6 ng/ml (EtG), 4.7 ng/ml (EtS), 12.5 ng/ml (NAcT), and 6.9 ng/ml (PEth) were in an acceptable range for routine applications, and the stability of all analytes over a range of 12 h is given. The verification of the new developed method was performed with authentic samples. Thus, whole blood and postmortem samples were analyzed to obtain information about the drinking behavior, which can answer complex questions regarding alcohol consumption.

Determination of Ethyl Glucuronide and Ethyl Sulfate in Human Whole Blood and Vitreous Humor by LC-MS-MS and Applications to the Interpretation of Postmortem Ethanol Findings

Identifying the source of ethanol in a decedent remained a complicated problem for forensic toxicologists because of postmortem ethanol formation. As ethanol's non-oxidative metabolites, ethyl glucuronide (EtG) and ethyl sulfate (EtS) have the potential to distinguish between antemortem ethanol consumption and postmortem ethanol formation, due to their high sensitivity and selectivity. In the current study, a simple and quick liquid chromatography tandem mass spectrometry (LC-MS/MS) method was developed for the determination of EtG and EtS in human whole blood and vitreous humor (VH). A total of 20 μL of the sample was precipitated by methanol, and the analytes were detected by LC-MS/MS in a run of 6 min. This method achieved high sensitivity (limits of detection: 2 ng/mL for both EtG and EtS), with linearity in the range of 5-10,000 ng/mL in both whole blood and VH. Deviations in accuracy, inter- and intra-day precision were all lower than 15% at three quality control levels. Subsequently, this method was applied to 62 real forensic cases. Only blood samples were available in 52 cases. Paired blood and VH samples were present in 10 cases. The concentrations of EtG and EtS in blood were in the range of 0-22,264.8 ng/mL and 0-2,126.0 ng/mL, respectively. In one case with both blood and VH, the blood ethanol concentration was 1.22 mg/mL, with EtG and EtS both below limits of quantification (5 ng/mL) in VH, and no EtG and EtS found in whole blood. The results suggested that EtG and EtS were useful markers for the interpretation of ethanol resource in postmortem blood and VH.

Secondary Analysis of a Randomized Clinical Trial of Naltrexone Among Women Living With HIV: Correlations Between Reductions in Self-Reported Alcohol Use and Changes in Phosphatidylethanol

BACKGROUND

Direct biomarkers such as phosphatidylethanol (PEth) have the capability to detect heavy alcohol use, but it is unclear how strongly self-reported reduction in alcohol use correlates with reduction in PEth. We sought to explore the strength of correlation between reductions in self-reported alcohol use and change in PEth among a sample of women living with HIV (WLWH) who participated in a clinical trial to reduce heavy alcohol use. We also sought to determine whether this correlation was stronger in women with lower body mass index (BMI) and women without an alcohol use disorder (AUD).

METHODS

81 WLWH (mean age = 48.7, 80% Black) engaging in a randomized trial of naltrexone versus placebo with a positive baseline PEth (≥8 ng/ml), and alcohol use data at baseline, 2, and 7 months were included in this analysis. Spearman correlation coefficients were compared to measure the correlation between baseline PEth and number of drinks per week by demographic, biological, and alcohol use factors. Mini-International Neuropsychiatric Interview was used to screen for AUD. Further analyses were stratified by BMI and AUD. Spearman correlation coefficients were calculated for the change in PEth and the change in number of drinks per week over 7 months, including 3 time-points: baseline, 2, and 7 months.

RESULTS

At baseline, the correlation between baseline PEth and the number of drinks per week was significantly stronger for those with a BMI ≤25 compared to those with a BMI > 25 (r = 0.66; r = 0.26, respectively). Similarly, the correlation between baseline PEth and number of drinks was stronger for those who did not screen positive for AUD compared with those who did (r = 0.66; r = 0.25, respectively). When stratifying by BMI, a low-to-moderate correlation (r = 0.32, p = 0.02) was present for persons with a BMI > 25; when stratifying by AUD, a moderate correlation (r = 0.50, p < 0.01) was present for persons without an AUD between 0 and 2 months only.

CONCLUSIONS

In this sample of WLWH, BMI and AUD affected the strength of correlation between PEth and drinks per week. Future work examining changes in PEth over time in broader populations is needed, particularly to understand the sex differences in PEth levels.

Wearable Electrochemical Sensors for the Monitoring and Screening of Drugs

Wearable electrochemical sensors capable of noninvasive monitoring of chemical markers represent a rapidly emerging digital-health technology. Recent advances toward wearable continuous glucose monitoring (CGM) systems have ignited tremendous interest in expanding such sensor technology to other important fields. This article reviews for the first time wearable electrochemical sensors for monitoring therapeutic drugs and drugs of abuse. This rapidly emerging class of drug-sensing wearable devices addresses the growing demand for personalized medicine, toward improved therapeutic outcomes while minimizing the side effects of drugs and the related medical expenses. Continuous, noninvasive monitoring of therapeutic drugs within bodily fluids empowers clinicians and patients to correlate the pharmacokinetic properties with optimal outcomes by realizing patient-specific dose regulation and tracking dynamic changes in pharmacokinetics behavior while assuring the medication adherence of patients. Furthermore, wearable electrochemical drug monitoring devices can also serve as powerful screening tools in the hands of law enforcement agents to combat drug trafficking and support on-site forensic investigations. The review covers various wearable form factors developed for noninvasive monitoring of therapeutic drugs in different body fluids and toward on-site screening of drugs of abuse. The future prospects of such wearable drug monitoring devices are presented with the ultimate goals of introducing accurate real-time drug monitoring protocols and autonomous closed-loop platforms toward precise dose regulation and optimal therapeutic outcomes. Finally, current unmet challenges and existing gaps are discussed for motivating future technological innovations regarding personalized therapy. The current pace of developments and the tremendous market opportunities for such wearable drug monitoring platforms are expected to drive intense future research and commercialization efforts.

Evaluation and review of ways to differentiate sources of ethanol in postmortem blood

Accurate determination of a person's blood alcohol concentration (BAC) is an important task in forensic toxicology laboratories because of the existence of statutory limits for driving a motor vehicle and workplace alcohol testing regulations. However, making a correct interpretation of the BAC determined in postmortem (PM) specimens is complicated, owing to the possibility that ethanol was produced in the body after death by the action of various micro-organisms (e.g., Candida species) and fermentation processes. This article reviews various ways to establish the source of ethanol in PM blood, including collection and analysis of alternative specimens (e.g., bile, vitreous humor (VH), and bladder urine), the identification of non-oxidative metabolites of ethanol, ethyl glucuronide (EtG) and ethyl sulfate (EtS), the urinary metabolites of serotonin (5-HTOL/5-HIAA), and identification of n-propanol and n-butanol in blood, which are known putrefaction products. Practical utility of the various biomarkers including specificity and stability is discussed.

Evaluating the hip-flask defence using analytical data from ethanol and ethyl glucuronide. A comparison of two models

AIM

Claimed intake of alcohol after a traffic incident, called the hip-flask defence, can be objectively assessed by different methods. One of them is the use of two consecutive ethanol concentrations in urine and the ratio between ethanol concentrations in urine and blood. Another one is the concentrations of ethyl glucuronide (EtG) and ethyl sulphate (EtS) in blood and their ratio to ethanol. The experimental basis for both these models is from single dose studies only. The aim of this study was therefore to describe the kinetics of ethanol, EtG and EtS after ingestion of two repeated doses of ethanol and to investigate the usefulness of the different models for the assessment of the hip-flask defence.

METHODS

Thirty-five subjects ingested a first dose of 0.51 g of ethanol per kilo body weight, and two hours later a second dose (the hip-flask drink) of 0.25, 0.51 or 0.85 g of ethanol per kilo body weight. Ten urine and 17 blood samples were collected and analysed for ethanol, EtG and EtS using fully validated methods. It was investigated if all subjects fulfilled the criteria for recent drinking, according to the two different models, when using the samples collected 180-240 minutes after start of first dose drinking. According to the first model, increase in urinary ethanol concentrations and a ratio UAC/BAC below 1.3 indicated recent drinking. According to the second model, increase in blood EtG concentrations and a ratio ethanol (g/kg)/EtG (mg/L) above 1 indicated recent drinking.

RESULTS

All subjects in the high dose group fulfilled all criteria for recent drinking. One subject in the medium dose group and nine subjects in the low dose group failed to show increasing UAC and/or a UAC/BAC ratio below 1.3. One subject in the low dose group failed to show increasing concentrations of blood EtG, but all subjects showed a ratio ethanol/EtG above 1.

CONCLUSIONS

The present study showed, by the use of experimental data, that both two models used to investigate the hip-flask defence can be used, but only when the hip-flask dose is sufficiently high.

The roles of phosphatidylethanol, ethyl glucuronide, and ethyl sulfate in identifying alcohol consumption among participants in professionals health programs

Direct alcohol biomarkers, including urinary ethyl glucuronide (EtG), urinary ethyl sulfate (EtS), and blood phosphatidylethanol (PEth), are used to monitor alcohol abstinence in individuals who are mandated to abstain. In this consecutive case series study, we examined 1000 forensic reports of participants enrolled in a professionals health program who were contractually obligated to abstain from alcohol and who underwent recovery status evaluations. We identified 52 evaluations in which urinary EtG, EtS, and blood PEth were measured and which produced a positive result for at least one of these analytes. PEth, at a cutoff concentration of 20 ng/mL, revealed alcohol use more frequently than EtG or EtS at our laboratory's cutoff concentrations of 100 and 25 ng/mL, respectively. This was true, as well, at alternative EtG/EtS cutoff concentrations of 200/50, 300/75, and 400/100 ng/mL. PEth was more likely than EtG/EtS to be positive in participants previously diagnosed with alcohol use disorders (AUD), whereas EtG/EtS was more likely than PEth to be positive in participants without AUD. In this study, blood PEth was the most sensitive biomarker for evidencing alcohol use.

What the lab can and cannot do: clinical interpretation of drug testing results

Urine drug testing is one of the objective tools available to assess adherence. To monitor adherence, quantitative urinary results can assist in differentiating "new" drug use from "previous" (historical) drug use. "Spikes" in urinary concentration can assist in identifying patterns of drug use. Coupled chromatographic-mass spectrometric methods are capable of identifying very small amounts of analyte and can make clinical interpretation rather challenging, specifically for drugs that have a longer half-life. Polypharmacy is common in treatment and rehabilitation programs because of co-morbidities. Medications prescribed for comorbidities can cause drug-drug interaction and phenoconversion of genotypic extensive metabolizers into phenotypic poor metabolizers of the treatment drug. This can have significant impact on both pharmacokinetic (PK) and pharmacodynamic properties of the treatment drug. Therapeutic drug monitoring (TDM) coupled with PKs can assist in interpreting the effects of phenoconversion. TDM-PKs reflects the cumulative effects of pathophysiological changes in the patient as well as drug-drug interactions and should be considered for treatment medications/drugs used to manage pain and treat substance abuse. Since only a few enzyme immunoassays for TDM are available, this is a unique opportunity for clinical laboratory scientists to develop TDM-PK protocols that can have a significant impact on patient care and personalized medicine. Interpretation of drug screening results should be done with caution while considering pharmacological properties and the presence or absence of the parent drug and its metabolites. The objective of this manuscript is to review and address the variables that influence interpretation of different drugs analyzed from a rehabilitation and treatment programs perspective.

Ethylene glycol: Evidence of glucuronidationin vivoshown by analysis of clinical toxicology samples

In the search for improved laboratory methods for the diagnosis of ethylene glycol poisoning, the in vivo formation of a glucuronide metabolite of ethylene glycol was hypothesized. Chemically pure standards of the β‐O‐glucuronide of ethylene glycol (EG‐GLUC) and a deuterated analog (d₄‐EG‐GLUC) were synthesized. A high‐performance liquid chromatography and tandem mass spectrometry method for determination of EG‐GLUC in serum after ultrafiltration was validated. Inter‐assay precision (%RSD) was 3.9% to 15.1% and inter‐assay %bias was −2.8% to 12.2%. The measuring range was 2–100 μmol/L (0.48–24 mg/L). Specificity testing showed no endogenous amounts in routine clinical samples (n = 40). The method was used to analyze authentic, clinical serum samples (n = 31) from patients intoxicated with ethylene glycol. EG‐GLUC was quantified in 15 of these samples, with a mean concentration of 6.5 μmol/L (1.6 mg/L), ranging from 2.3 to 15.6 μmol/L (0.55 to 3.7 mg/L). In five samples, EG‐GLUC was detected below the limit of quantification (2 μmol/L) and it was below the limit of detection in 11 samples (1 μmol/L). Compared to the millimolar concentrations of ethylene glycol present in blood after intoxications and potentially available for conjugation, the concentrations of EG‐GLUC found in clinical serum samples are very low, but comparable to concentrations of ethyl glucuronide after medium dose ethanol intake. In theory, EG‐GLUC has a potential value as a biomarker for ethylene glycol intake, but the pharmacokinetic properties, in vivo/vitro stability and the biosynthetic pathways of EG‐GLUC must be further studied in a larger number of patients and other biological matrices.

Ethyl glucuronide hair testing: A review

Ethyl glucuronide (EtG) is a minor, non-oxidative ethanol metabolite that can be detected in several matrices (e.g. blood, urine, hair, meconium) for variable periods of time. Quantification of EtG in hair (hEtG) has established itself, over recent years, as one of the most reliable biomarkers of long-term alcohol consumption habits, with the Society of Hair Testing (SoHT) offering cut-off values for assessment of both abstinence and heavy drinking (>60 g/day). Despite its high diagnostic performance, however, issues concerning inter- and intra-laboratory variability as well as data interpretation are still being investigated and represent the ultimate barrier to widespread acceptance of hEtG in the forensic context. The aim of this review is to summarize currently available analytical methods of hEtG testing, provide a framework to understand current hEtG cut-offs and their possible upcoming changes (in particular, a lower abstinence cut-off has been proposed for the 2019 revision of the SoHT consensus), and offer a schematic but exhaustive overview of the pitfalls in result reproducibility and interpretation that may limit applications of hEtG testing in the forensic context. Ultimately, the purpose of the authors is not to undermine the reliability of hEtG as an alcohol use marker, but rather to enhance it by promoting familiarization with all aspects related to it, from ethanol pharmacokinetics and EtG incorporation into hair, to sample preparation and analytical methods, to specific cases warranting close attention and additional tests for correct interpretation of hEtG results.

Pharmacokinetics of Phosphatidylethanol 16:0/20:4 in Human Blood After Alcohol Intake

BACKGROUND

The purpose of this study was to characterize the pharmacokinetics of the phosphatidylethanol (PEth) 16:0/20:4 homolog in uncoagulated human blood samples taken from 18 participants in a clinical laboratory setting after consumption of 2 standard doses of ethanol (EtOH).

METHODS

Male and female participants received either 0.4 or 0.8 g/kg oral doses of EtOH during a 15-minute period. Blood samples were collected before and throughout 6 hours immediately after alcohol administration and then again at days 2, 4, 7, 11, and 14 of the follow-up period. PEth 16:0/20:4 levels were quantified by high-performance liquid chromatography with tandem mass spectrometry detection.

RESULTS

(i) The increase in PEth 16:0/20:4 from baseline to maximum concentration was less than that of PEth 16:0/18:1 or PEth 16:0/18:2 homologs during the 6-hour period after EtOH administration; (ii) the mean half-life of PEth 16:0/20:4 was 2.1 ± 3 (SD) days, which was shorter than the mean half-life of either PEth 16:0/18:1 or PEth 16:0/18:2, 7.6 ± 3 (SD) or 6.8 ± 4 (SD) days, respectively.

CONCLUSIONS

The pharmacokinetics of PEth 16:0/20:4 in whole blood samples is detectable after alcohol consumption and differs in amount synthesized and rate of elimination versus PEth 16:0/18:1 and 16:0/18:2. Measuring the concentrations of these 3 homologs has the potential to provide more information about the amount and time frame of alcohol consumption than any one alone.

Assessment of ethyl sulphate in hair as a marker for alcohol consumption using liquid chromatography-tandem mass spectrometry

Ethyl glucuronide (EtG) and ethyl sulphate (EtS) are 2 non-oxidative and direct metabolites of ethanol. EtG is known to accumulate in hair and has proved to be a reliable biomarker for detection of chronic alcohol consumption. EtS has been analysed in blood and urine but has never been reported in hair. This article presents the first analytical assay based on liquid chromatography coupled to tandem mass spectrometry for the quantification of EtS in hair. Sample preparation, chromatographic, and mass spectrometric parameters, such as solid-phase extraction, column type, and transitions were optimised. The method was validated according to the guidelines of the European Medicine Agency, fulfilling the requirements for limit of quantification (LOQ), linearity, accuracy, precision, carry-over, matrix effects, and recovery. Linearity ranged from 5 to 500 pg mg^-1 and the LOQ was achieved at 5 pg mg^-1 . The novel method was successfully applied to hair samples (n = 40) from patients treated for alcohol use disorders. EtS concentrations in hair ranged from 24 to 1776 pg mg^-1 , while EtG concentrations in hair ranged from 1 to 1149 pg mg^-1 . Hair concentrations of EtS and EtG were compared to assess the relationship between both biomarkers. There was a significant and positive correlation between EtS and EtG in hair, suggesting that EtS can be used as a biomarker for alcohol consumption. Relatively high basal EtS levels were observed in alcohol-abstinent persons, comparable to what has been reported for EtG. The developed analytical procedure offers an alternative method to prove alcohol consumption using hair analysis.

Value of Ethyl Glucuronide and Ethyl Sulfate in Serum as Biomarkers of Alcohol Consumption

BACKGROUND

Urinary Ethyl glucuronide (EtG) and Ethyl sulfate (EtS) are established markers of alcohol conumption. Measurement of these markers in serum offers certain advantages. This outpatient department based study evaluated performance of serum Ethyl glucuronide (EtG) and Ethyl sulphate (EtS) as biomarkers of recent alcohol consumption in alcohol dependent subjects. It also evaluated effect of alcohol dose and time since consumption on serum EtG and EtS concentration.

METHODS

Information regarding alcohol intake was collected using Time line follow back calendar method from 152 subjects. Blood samples were collected to determine serum EtG and EtS concentration.

RESULTS

The results revealed that serum EtG (at a threshold of 45 ng/mL) could detect recent moderate to heavy alcohol consumption with 85 percent sensitivity and 89 percent specificity. The results also show that simultaneous measurement of EtS does not increase test accuracy. We found that dose of alcohol and time since alcohol consumption explain 68 and 62 percent variance in serum EtG and EtS levels.

CONCLUSION

EtG testing in blood was found useful as a way to detect recent drinking. This sensitive and specific short-term biomarker provides valuable information about recent alcohol consumption.

EtG and EtS in Autopsy Blood Samples With and Without Putrefaction Using UPLC-MS-MS

Analytical challenges related to postmortem specimens are well known. The degree of putrefaction of the corpse will influence the quality of the blood samples, and both the efficiency of sample preparation and the subsequent chromatographic performance can be affected. An ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS-MS) method was developed and validated for the determination of ethyl glucuronide (EtG) and ethyl sulfate (EtS) in postmortem whole blood. Sample preparation prior to UPLC-MS-MS analysis consisted of protein precipitation and filtration through a phospholipid removal plate. Chromatography was achieved using an HSS T3 column and gradient elution with formic acid in water in combination with methanol. The injection volume was 0.5 µL. Negative electrospray ionization was performed in the multiple reaction monitoring mode. Two transitions were monitored for the analytes and one for the internal standards. The between-assay relative standard deviations were in the range of 1.7-7.0% and the limits of quantification were 0.025 and 0.009 mg/L for EtG and EtS, respectively. Recovery was 51-55% and matrix effects ranged from 98% to 106% (corrected with internal standard). Blood samples from nine autopsy cases with various extents of putrefaction were analyzed. The sample preparation efficiently removed the phospholipids from the blood specimens. The samples were clean and the analytical quality of the chromatographic performance was satisfactory for both analytes irrespective of the degree of putrefaction.

Simultaneous determination of ethanol's four types of non-oxidative metabolites in human whole blood by liquid chromatography tandem mass spectrometry

The importance of ethanol non-oxidative metabolites as the specific biomarkers of alcohol consumption in clinical and forensic settings is increasingly acknowledged. Simultaneous determination of these metabolites can provide a wealth of information like drinking habit and history, but it was difficult to achieve because of their wide range of polarity. This work describes development and validation of a simple liquid chromatography tandem mass spectrometry (LC-MS/MS) assay for 4 types of ethanol non-oxidative metabolites (ethyl glucuronide, ethyl sulfate, fatty acid ethyl esters and phosphatidylethanols) in 50 μL of human whole blood. Pretreatment method, column and MS conditions were optimized. For the first time, the four types of ethanol non-oxidative metabolites with enormous discrepancies of property were simultaneously extracted and analyzed in one run within 40 min. The limits of detections (LODs) were among 0.1-10 ng/mL, and good linearity was obtained. Deviations in precision and accuracy were all lower than 15% at three QC levels. This method was then applied to two forensic samples, resulting in information on drinking habits and drinking time which were very useful for the interpretation of the blood alcohol results.

Alternative sampling strategies for the assessment of alcohol intake of living persons

Monitoring of alcohol consumption by living persons takes place in various contexts, amongst which workplace drug testing, driving under the influence of alcohol, driving licence regranting programs, alcohol withdrawal treatment, diagnosis of acute intoxication or fetal alcohol ingestion. The matrices that are mostly used today include blood, breath and urine. The aim of this review is to present alternative sampling strategies that allow monitoring of the alcohol consumption in living subjects. Ethanol itself, indirect (carbohydrate deficient transferrin, CDT%) as well as direct biomarkers (ethyl glucuronide, EtG; ethyl sulphate, EtS; fatty acid ethyl esters, FAEEs and phosphatidylethanol species, PEths) of ethanol consumption will be considered. This review covers dried blood spots (CDT%, EtG/EtS, PEths), dried urine spots (EtG/EtS), sweat and skin surface lipids (ethanol, EtG, FAEEs), oral fluid (ethanol, EtG), exhaled breath (PEths), hair (EtG, FAEEs), nail (EtG), meconium (EtG/EtS, FAEEs), umbilical cord and placenta (EtG/EtS and PEth 16:0/18:1). Main results, issues and considerations specific to each matrix are reported. Details about sample preparation and analytical methods are not within the scope of this review.

A wearable biochemical sensor for monitoring alcohol consumption lifestyle through Ethyl glucuronide (EtG) detection in human sweat

We demonstrate for the first time a wearable biochemical sensor for monitoring alcohol consumption through the detection and quantification of a metabolite of ethanol, ethyl glucuronide (EtG). We designed and fabricated two co-planar sensors with gold and zinc oxide as sensing electrodes. We also designed a LED based reporting for the presence of EtG in the human sweat samples. The sensor functions on affinity based immunoassay principles whereby monoclonal antibodies for EtG were immobilized on the electrodes using thiol based chemistry. Detection of EtG from human sweat was achieved through chemiresistive sensing mechanism. In this method, an AC voltage was applied across the two coplanar electrodes and the impedance across the sensor electrodes was measured and calibrated for physiologically relevant doses of EtG in human sweat. EtG detection over a dose concentration of 0.001–100 μg/L was demonstrated on both glass and polyimide substrates. Detection sensitivity was lower at 1 μg/L with gold electrodes as compared to ZnO, which had detection sensitivity of 0.001 μg/L. Based on the detection range the wearable sensor has the ability to detect alcohol consumption of up to 11 standard drinks in the US over a period of 4 to 9 hours.

Population Baseline of Meconium Ethyl Glucuronide and Ethyl Sulfate Concentrations in Newborns of Nondrinking Women in 2 Mediterranean Cohorts

The detection of ethyl glucuronide (EtG) and ethyl sulfate (EtS) in meconium has been investigated recently as an alternative to meconium fatty acid ethyl esters (FAEEs) measurement as an objective estimate of prenatal alcohol exposure, independent of maternal self-reporting. We report the results of the first study conducted to investigate the concentrations of EtG and EtS in meconium from newborns with and without intrauterine exposure to ethanol, defined by questionnaire and meconium FAEEs concentration. FAEEs, EtG, and EtS were quantified by liquid chromatography tandem mass spectrometry in meconium samples obtained from the Arcispedale Santa Maria Nuova, Reggio Emilia, Italy (n = 80) and from the Hospital del Mar in Barcelona, Spain (n = 105). Median EtG and EtS values in meconium from newborns without intrauterine exposure to ethanol varied between 0.100 and 0.140 nmol/g and 0.010 and 0.020 nmol/g in Reggio Emilia and Barcelona samples, respectively. In meconium from newborns with uncertain prenatal ethanol exposure, the EtG median value was 0.160 nmol/g in the Italian cohort and 0.250 nmol/g in the Spanish one. The median EtS concentration was 0.020 in both cohorts. EtG and EtS median values in 5 meconium samples from newborns of heavily drinking mothers were 7.240 nmol/g and 0.033 nmol/g, respectively. A positive cutoff of 2.0 nmol/g for EtG yielded the best sensitivity and specificity (100%) to discriminate for true prenatal exposure to ethanol. It was not possible to establish a proper cutoff for EtS because of the low number of positive samples. Based on our results, meconium EtG can be proposed as an alternate biomarker for intrauterine alcohol exposure. In contrast to the 7 FAEEs, EtG is just one molecule that could be screened in meconium samples from all newborns by a simple, low-cost, easy-to-perform immunoassay, which can be routinely applied in neonatology wards for the early diagnosis of prenatal exposure to ethanol.

Evaluation of the hip-flask defence by determination of ethyl glucuronide and ethyl sulphate concentrations in blood

INTRODUCTION

The hip-flask defence (i.e. claiming ethanol intake after an incident) is difficult to refute by the use of ethanol analyses alone, as these may show decreasing concentrations shortly after intake of alcohol. The non-oxidative metabolites of ethanol, ethyl glucuronide (EtG) and ethyl sulphate (EtS) have a different pharmacokinetic profile, with peak concentrations in blood around 4h after intake. The aim of this study was to describe a method for using EtG-analysis for the purpose of estimating the time point of ethanol intake and to report cases in which this method is used.

METHODS

Previously published studies are summarised. Also, in expert witness cases where the hip-flask defence is claimed, EtG and EtS were analysed in selected cases. Twelve such cases are reported.

RESULTS

In previous studies, about 70 healthy volunteers have been included in different kinetic studies, demonstrating maximal individual concentrations of EtG always below 0.5 mg/L after 1 h, below 1 mg/L after 2 h and somewhat above 1 mg/L 4 h after a moderate alcohol intake (up to 80 grams of ethanol). Twelve cases are reported in the present study, where the suspect claimed no alcohol intake before driving, only intake after driving. In all 12 cases, ethanol concentration was lower in the second sample (taken approximately 30 min after the first). The median EtG concentration in the first sample was 4.13 mg/L (range 2.0-7.4) and 4.34 mg/L (range 2.1-7.2) in the second sample. One case showed an increase in EtG concentrations of 15% from first to second sample (the time difference between the samples was 32 min, with the first sample taken 41 min after driving). For the remainder of the cases, EtG concentrations were relatively stable.

CONCLUSIONS

In all the presented cases, the levels of EtG were substantially higher than what would be expected only about 1-2h after a very recent alcohol intake. The relatively stable concentrations between the first and second sample also indicated that the high EtG concentrations were not caused by a rapid formation after a recent intake, as this would have demonstrated increasing concentrations over a time period of 30 min. In conclusion, EtG and EtS in blood could be a helpful tool in assessment of the hip-flask defence, in cases where the detected ethanol is claimed to be caused solely by a single intake after driving.

Alcohol hangover as a cause of impairment in apprehended drivers

OBJECTIVE

Previous studies have already shown the possibility of impairment during a hangover phase, after alcohol ingestion, when the blood alcohol concentration has returned to zero. The prevalence of drivers being in a hangover phase, in the driving population, and the relation to impairment relevant for traffic safety has, however, not been previously studied. The aim of this study was to investigate the prevalence and the concentrations of the 2 ethanol metabolites, ethyl glucuronide (EtG) and ethyl sulfate (EtS), in blood, indicating very recent alcohol intake, among apprehended drivers, in which no psychoactive substances, including alcohol, were detected. The aim was also to study these findings in relation to the impairment observed in these drivers.

METHODS

Blood samples, drawn from suspected drunk or drugged drivers, were analyzed for a broad repertoire of psychoactive substances, with a clinical test for impairment (CTI) being performed at the same time. One hundred and forty-six cases, in which no psychoactive substances were detected and where a valid CTI was performed, were analyzed for EtG and EtS in blood. The prevalence and concentrations were related to the conclusions of the CTIs.

RESULTS

EtS and EtG were detected in a total of 19 of the 146 cases (13%). Among the "impaired" drivers, EtG and EtS were detected in 16 cases (18%), whereas among "not impaired" drivers they were detected in 3 cases (5%). There were significantly more detections of EtS (and EtG) among the impaired group of drivers compared to the nonimpaired drivers (P =.030), and the concentrations of both EtG (P =.027) and EtS (P =.026) were significantly higher in the group of impaired drivers compared to the nonimpaired drivers. There was a statistically significant positive correlation between the concentrations of EtG (Spearman's rho = 0.170, P =.041) and EtS (Spearman's rho = 0.189, P =.022) and the degree of impairment.

CONCLUSIONS

EtG and EtS were prevalent findings in blood collected from the apprehended drivers, testing negative for all psychoactive substances. The higher rates of detections of EtG and EtS in impaired compared to nonimpaired drivers, and also the positive correlation between concentrations of EtG and EtS and the degree of impairment, indicate that hangover symptoms may be relevant for traffic safety.

Prevalence of ethyl glucuronide and ethyl sulphate among patients injured when driving or at work

AIMS

Presence of EtG or EtS among patients injured when driving or at work may indicate that very low BAC or residual effects of alcohol at the time of the accident may be associated with increased accident risk. The aim of this study was to assess: whether the alcohol metabolites EtG and EtS were present in a sample of patients injured when driving or injured at work, even if their blood alcohol concentration was negative; and, if EtG and EtS were present, what characterized these patients.

METHODS

Blood samples from patients admitted for treatment of injuries at a Norwegian emergency department were tested for alcohol, EtG and EtS. All samples were also analysed for medicinal and illicit psychoactive substances.

RESULTS

One hundred and ninety-two injured patients who were admitted <12 h after injury were included in the study. EtG or EtS were the most prevalent substances in the sample (17%), and a substantial proportion of the patients who tested negative for all other substances tested positive for EtG or EtS (8%). These patients were older than the rest of the sample and drank alcohol more often, according to their self-report.

CONCLUSION

EtG and EtS were prevalent among patients injured when driving or injured at work, including patients negative for all other substances. EtG and EtS should be included in future case-control studies of psychoactive substance use among injured patients to investigate the possible association between residual alcohol effects and injuries.

Ethyl glucuronide and ethyl sulfate assays in clinical trials, interpretation, and limitations: results of a dose ranging alcohol challenge study and 2 clinical trials

BACKGROUND

The ethanol metabolites, ethyl glucuronide (EtG) and ethyl sulfate (EtS), are biomarkers of recent alcohol consumption that provide objective measures of abstinence. Our goals are to better understand the impact of cutoff concentration on test interpretation, the need for measuring both metabolites, and how best to integrate test results with self-reports in clinical trials.

METHODS

Subjects (n = 18) were administered, 1 week apart, 3 alcohol doses calibrated to achieve blood concentrations of 20, 80, and 120 mg/dl, respectively. Urinary EtG/EtS was measured at timed intervals during a 24-hour hospitalization and twice daily thereafter. In addition, participants from 2 clinical trials provided samples for EtG/EtS and drinking histories. Cutoffs for EtG/EtS of 100/50, 200/100, and 500/250 ng/ml were evaluated.

RESULTS

Twelve hours following each challenge, EtG was always positive at the 100 and 200 cutoffs, but at 24 hours sensitivity was poor at all cutoffs following the low dose, and poor after 48 hours regardless of dose or cutoff. Similarly, in the clinical trials EtG sensitivity was good for detecting any drinking during the last 24 hours at the 2 lowest cutoffs, but under 40% during the last 24 to 48 hours. Sensitivity was reduced at the 500 ng/ml cutoff. Discrepancies between EtG and EtS were few. Comparison of self-reports of abstinence and EtG-confirmed abstinence indicated underreporting of drinking.

CONCLUSIONS

Any drinking the night before should be detectable the following morning with EtG cutoffs of 100 or 200 ng/ml. Twenty-four hours after drinking, sensitivity is poor for light drinking, but good for heavier consumption. At 48 hours, sensitivity is low following 6 drinks or less. Increasing the cutoff to 500 ng/ml leads to substantially reduced sensitivity. Monitoring both EtG and EtS should usually be unnecessary. We recommend EtG-confirmed self-reports of abstinence for evaluation of outcomes in clinical trials.

Ethyl glucuronide and ethyl sulfate

Alcohol misuse is associated with significant morbidity and mortality. Although clinical history, examination, and the use of self-report questionnaires may identify subjects with harmful patterns of alcohol use, denial or under-reporting of alcohol intake is common. Existing biomarkers for detecting alcohol misuse include measurement of blood or urine ethanol for acute alcohol consumption, and carbohydrate-deficient transferrin and gamma-glutamyl transferase for chronic alcohol misuse. There is a need for a biomarker that can detect excessive alcohol consumption in the timeframe between 1 day and several weeks. Ethyl glucuronide (EtG) is a direct metabolite of ethanol detectable in urine for up to 90 h and longer in hair. Because EtG has high specificity for excess alcohol intake, it has great potential for use in detecting "binge" drinking. Using urine or hair, this noninvasive marker has a role in a variety of clinical and forensic settings.

Comparison of ethyl glucuronide and carbohydrate-deficient transferrin in different body fluids for post-mortem identification of alcohol use

AIMS

Alcohol abuse is a major risk factor for premature death. Confirming the role of alcohol consumption in cause-of-death investigations has, however, remained difficult, due to lack of reliable biomarkers.

METHODS

We compared ethyl glucuronide (EtG) and carbohydrate-deficient transferrin (CDT) assays from serum, urine, cerebrospinal fluid and vitreous humor in a forensic autopsy population with either a positive (n = 38) or negative (n = 22) history of alcohol abuse based on detailed medical and police records and forensic toxicological investigations.

RESULTS

A positive blood alcohol concentration (median 1.15‰, range 0-3.3‰) was found in 26/38 (68%) of the cases with a documented history of alcohol abuse. EtG concentrations (mean ± SD) in urine (339 ± 389 mg/l, P < 0.001), vitreous humor (4.2 ± 4.8 mg/l, P < 0.001), serum (6.9 ± 8.9 mg/l, P < 0.01) and cerebrospinal fluid (1.7 ± 2.7 mg/l, P < 0.01) were significantly higher among the cases with a positive history of alcohol use than those in the alcohol-history negative group, whereas in corresponding comparisons CDT was significantly different only in cerebrospinal fluid (4.3 ± 2.1 vs. 2.3 ± 0.6%, P < 0.05). The highest sensitivities (92%) in detecting ante-mortem alcohol use were obtained for urine and vitreous humor EtG assays.

CONCLUSION

Our data indicate that measurements of EtG in urine or vitreous humor show the highest diagnostic accuracies in post-mortem investigations of excessive alcohol consumption and can be recommended for routine applications.

Less glucuronidation of morphine in the presence of ethanol in vivo

PURPOSE

Ethanol and morphine are both substrates of uridine diphosphate glucuronosyl transferases (UGTs). A pharmacokinetic interaction between ethanol and morphine is suggested from in vitro studies, but to our knowledge not documented in vivo. The aim of this study was to compare the ratios between M6G and morphine and between M3G and morphine in blood samples from suspected drunk and drugged drivers, with and without presence of ethanol.

METHODS

The data in the present study constitute all cases of suspected drunk and drugged driving positive for morphine, collected in Norway, in the period November 1st 2009 to December 1st 2012, during which all morphine positive cases were also routinely analysed for M6G and M3G. The cases were divided into two groups; one where morphine was present together with ethanol (group 1) and one where morphine was present in the absence of ethanol (group 2).

RESULTS

The ratios between M3G and morphine was lower in the ethanol positive cases, i.e. mean 4.9 (95 % CI 4.03-5.79) in group 1 and mean 6.7 (95 % CI 6.35-7.00) in group 2 (p < 0.001). The ratios between M6G and morphine was also lower in the ethanol positive cases, i.e. mean 0.62 (95 % CI 0.42-0.81) in group 1 and mean 0.96 (95 % CI 0.89-1.02) in group 2 (p = 0.001).

CONCLUSIONS

This study indicated that the metabolism of morphine may be changed in the presence of ethanol, resulting in less formation of the metabolites. This could lead to increased terminal half-life for morphine and also possibly more accumulation after repeated dosing.

Studying psychoactive substance use in injured patients: does exclusion of late arriving patients bias the results?

BACKGROUND

Most studies of the prevalence of psychoactive substances in injured emergency department patients have excluded those who arrive more than 6h after injury. This may cause a selection bias. The aim of this study was: (1) to describe the characteristics of patients who arrive more than 6h after injury, compared to patients who arrive sooner (2) to examine whether self-report can add to the assessment of alcohol use when the patient is assessed more than 6h after injury.

METHODS

Blood sample analysis and self-report data were used to assess the prevalence of psychoactive substances in injured patients admitted to an emergency department within 48 h of injury (n=1611). Discriminant function analysis was used to assess group differences.

RESULTS

The patients who arrived more than 6h after injury differed significantly from those who arrived earlier in several respects. They more often screened positive for hypnotics; they were older, they were more likely to have had a fall and they were more often injured at home and at night. Self reported use of alcohol showed good consistency with blood sample screening within 6h of injury and could therefore be used to assess alcohol use more than 6h after injury.

CONCLUSIONS

Patients who arrive more than 6h after injury differ significantly from those who arrive earlier. Future studies on the prevalence of psychoactive substances in emergency departments could expand the inclusion window.

Higher levels of hair ethyl glucuronide in patients with decreased kidney function

BACKGROUND

Hair levels of ethyl glucuronide (EtG) are often used to differentiate social drinking from heavy drinking. Patients with decreased kidney function have delayed excretion of EtG, and increased incorporation into hair could be suspected. The aim of this study was to compare hair EtG levels in patients with decreased kidney function to those seen in healthy volunteers.

METHODS

Twelve patients with renal disease were included. The levels of EtG in hair were adjusted to estimated daily intake of ethanol (EDI) and compared to 21 previously published healthy individuals.

RESULTS

The levels of hair EtG in the 12 patients ranged between < limit of detection and 134 pg/mg, and the EDI ranged between 0.1 and 12 g. The levels of EtG in hair were significantly higher in the patients compared to healthy volunteers (p = 0.009).

CONCLUSIONS

These preliminary results indicate that hair levels of EtG in a population of patients with decreased kidney function should be interpreted with caution.

IGF-I and IGFBP-3 before and after inpatient alcohol detoxification in alcohol-dependent subjects

Background

It is unclear whether alcohol detoxification has an effect on factors that are involved in growth, metabolic functions and cell proliferation. Alcohol abuse is associated with low IGF-I levels that tend to rise after alcohol withdrawal. There is a paucity of studies on the course of IGFBP-3 (the main binding protein for IGF-I) after alcohol detoxification.

Material/Methods

We prospectively assessed IGF-I and IGFBP-3 changes at the time of admission and after 4 to 6 weeks of detoxification in an inpatient alcohol detoxification facility in 118 alcohol-dependent subjects given a regular hospital diet. No participants dropped out of the study.

Results

Changes in IGF-I after alcohol detoxification showed a marked dimorphism in altered hepatic biochemistry upon admission, with a rise in those with normal liver enzymes upon admission (p=0.016, Kruskall-Wallis) and a drop in those with elevated liver enzymes upon admission (p=0.05); the latter was noted in subjects that had consumed alcohol close to the time of admission. Overall, however, IGF-I and IGFBP-3 were within normal limits for most subjects both upon admission and after alcohol detoxification; no significant differences were detected among the examined parameters in men vs. women, and there were no significant correlations of IGF-I, IGFBP-3 or the IGF-I/IGFBP-3 molar ratio with BMI or age.

Conclusions

Regardless of hepatic enzymes’ elevation, alcohol detoxification had overall slight effects on IGF-I and IGFBP-3.

Ethyl glucuronide

Alcohol is associated with significant morbidity and mortality. Subjects abusing alcohol can be identified through clinical history, examination or self-report questionnaires. A range of biomarkers is available for detecting alcohol misuse, but there is still a need for a marker that can detect alcohol consumption in the time window between one day (ethanol) and one week (gamma-glutamyl transpeptidase and carbohydrate-deficient transferrin). Ethyl glucuronide is a direct metabolite that can be detected in urine for up to 90 h and has the potential to become a useful marker of 'binge' drinking. As a non-invasive marker, it could have a role in a variety of clinical and forensic settings.

Analysis and interpretation of specific ethanol metabolites, ethyl sulfate, and ethyl glucuronide in sewage effluent for the quantitative measurement of regional alcohol consumption

BACKGROUND

The quantitative measurement of urinary metabolites in sewage streams and the subsequent estimation of consumption rates of the parent compounds have previously been demonstrated for pharmaceuticals and narcotics. Ethyl sulfate and ethyl glucuronide are excreted in urine following the ingestion of alcohol, and are useful biomarkers for the identification of acute alcohol consumption. This study reports a novel ion-exchange-mediated chromatographic method for the quantitative measurement of ethyl sulfate and ethyl glucuronide in sewage effluent, and presents a novel calculation method for the purposes of relating the resulting sewage concentrations with rates of alcohol consumption in the region.

METHODS

A total of 100 sewage samples covering a 25-day period were collected from a treatment plant servicing approximately 500,000 people, and analyzed for levels of ethyl sulfate and ethyl glucuronide. The resulting data were then used to estimate combined alcohol consumption rates for the region, and the results were compared with alcohol related sales statistics for the same region.

RESULTS

Ethyl glucuronide was found to be unstable in sewage effluent. Ethyl sulfate was stable and measurable in all samples at concentrations ranging from 16 to 246 nM. The highest concentrations of the alcohol biomarker were observed during weekend periods. Sixty one percent of the total mass of ethyl sulfate in sewage effluent corresponds to alcohol consumption on Friday and Saturday. Sales statistics for alcohol show that consumption in the region is approximately 6,750 kg/d. The quantity of ethyl sulfate passing through the sewage system is consistent with consumption of 4,900 to 7,800 kg/d.

CONCLUSIONS

  Sewage epidemiology assessments of ethyl sulfate can provide accurate estimates of community alcohol consumption, and detailed examination of the kinetics of this biomarker in sewage streams can also identify time-dependent trends in alcohol consumption patterns.

Optimizing heroin-assisted treatment (HAT): assessment of the contribution of direct ethanol metabolites in identifying hazardous and harmful alcohol use

BACKGROUND

Heavy alcohol consumption may accelerate the progression of hepatitis C-related liver disease and/or limit efforts at antiviral treatment in opioid-dependent patients receiving heroin-assisted treatment (HAT). Our study aims to assess alcohol intake among HAT patients by self-reports compared to direct ethanol metabolites.

METHOD

Fifty-four patients in HAT were recruited from the centre for HAT at the University of Basel, Switzerland. The patients completed the Alcohol Use Disorder Identification Test (AUDIT), a self-report questionnaire on past-week ethanol intake and provided samples for the determination of ethyl glucuronide (UEtG) and ethyl sulphate (UEtS) in urine and of ethyl glucuronide (HEtG) in hair.

RESULTS

Eighteen patients scored above the AUDIT cut-off levels. Twenty-six patients tested positive for UEtG and 29 for UEtS. HEtG identified ethanol intake of more than 20 g/d in 20 additional cases that did not appear in the AUDIT. Using the total score of the AUDIT, HEtG detected 14 additional cases of relevant alcohol intake.

CONCLUSIONS

The findings of this study, which is the first assessing alcohol intake in HAT patients using direct ethanol metabolites and self reports, suggest the complementary use of both. Improved detection of hazardous or harmful alcohol consumption in the context of HCV and heroin dependence will allow for earlier intervention in this population. This ultimately will contribute to an improvement in quality of life of patients in HAT. Furthermore, a significant reduction of costs can be achieved through a reduction of complications caused by alcohol intake.