Post-mortem quetiapine concentrations in hair segments of psychiatric patients - Correlation between hair concentration, dose and concentration in blood

Quetiapine-Related Deaths: In Search of a Surrogate Endpoint

Quetiapine is a second-generation antipsychotic drug available for two and half decades. Due to increased misuse, prescription outside the approved indications, and availability on the black market, it is being encountered in medicolegal autopsies more frequently. For instance, it has been linked to increased mortality rates, most likely due to its adverse effects on the cardiovascular system. Its pharmacokinetic features and significant postmortem redistribution challenge traditional sampling in forensic toxicology. Therefore, a systematic literature review was performed, inclusive of PubMed, the Web of Science-core collection, and the Scopus databases; articles were screened for the terms "quetiapine", "death", and "autopsy" to reevaluate each matrix used as a surrogate endpoint in the forensic toxicology of quetiapine-related deaths. Ultimately, this review considers the results of five studies that were well presented (more than two matrices, data available for all analyses, for instance). The highest quetiapine concentrations were usually measured in the liver tissue. As interpreted by their authors, the results of the considered studies showed a strong correlation between some matrices, but, unfortunately, the studies presented models with poor goodness of fit. The distribution of quetiapine in distinct body compartments/tissues showed no statistically significant relationship with the length of the postmortem interval. Furthermore, this study did not confirm the anecdotal correlation of peripheral blood concentrations with skeletal muscle concentrations. Otherwise, there was no consistency regarding selecting an endpoint for analysis.

Determination of ten antipsychotics in blood, hair and nails: Validation of a LC-MS/MS method and forensic application of keratinized matrix analysis

Determination of antipsychotics from biological samples is meaningful in the field of clinical and forensic medicine. Compared to blood, keratinized matrices such as hair and nails have attracted increasing attention in drug analysis for wider detection window. Nevertheless, the distribution and stability of antipsychotics in keratinized matrices are not clarified yet. Therefore, we developed a LC-MS/MS based method for simultaneous determination of 10 antipsychotics from blood, hair and nails, with high recovery (78.1-107.4%, 71.3-93.5% and 75.2-90.5%), low LOD (5-10 pg/mL, 5-10 pg/mg and 5 pg/mg) and high accuracy (96.0%-101.6%, 97.5%-102.5% and 97.6-101.7%). The method was applied to sets of blood, hair, and nail samples of 54 patients who received long-term therapy, and significant correlations between drug concentrations in blood and hair was found, while the correlation between nails and other matrices varied depending on the drug. Except for olanzapine, the concentrations of antipsychotics in segmental hair samples were consistent with drug exposure. Besides, the hair and nail samples of suspects in two forensic cases were analyzed and provided supporting evidence for the suspects' psychiatric state. Our research offered a deeper understanding of keratinized matrix as stable and retrospective bio-samples for antipsychotics detection in forensic practice.

Noninvasive drug adherence monitoring of antipsychotic patients via finger sweat testing

Collection of finger sweat is explored here as a rapid and convenient way of monitoring patient adherence to antipsychotic drugs. Finger sweat samples (n = 426) collected from patients receiving treatment with clozapine, quetiapine and olanzapine were analysed by liquid chromatography mass spectrometry, including a subgroup of patients with paired plasma samples. Finger sweat samples were also analysed from a negative control group and patients who had handled antipsychotic medication only. The finger sweat test (based on the detection of parent drug in one donated sample) was 100% effective in monitoring adherence within commonly prescribed dosing ranges. In comparison to participants who handled the medication only, the test could distinguish between contact and administration through monitoring of the drug metabolite, or the level of parent drug. Additionally, in a subgroup of patients prescribed clozapine, a statistically significant correlation was observed between the mass of parent drug in finger sweat and plasma concentration. The finger sweat technology shows promise as a dignified, noninvasive method to monitor treatment adherence in patients taking antipsychotics.

Analysis of conventional and nonconventional forensic specimens in drug-facilitated sexual assault by liquid chromatography and tandem mass spectrometry

The incidence of drug-facilitated sexual assault (DFSA) has dramatically increased in the last decades. Forensic analytical scientists continuously seek new methods and specimens to prove the incidence of intoxication for the judiciary system. Factors influencing sample selection include the ease of obtaining the samples and the window of detection of the drugs, among others. Both conventional (blood, urine) and non-conventional specimens (hair, nails, fluids) have been proposed as suitable in DFSA cases. Reported sample treatments include a variety of liquid-liquid and solid-phase extraction as well as dilute-and-shoot procedures and microextraction techniques. Regarding analysis, liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) has emerged as the preferred confirmatory technique, due to its sensitivity, selectivity, and wide-scope applicability. In this review, we critically discuss the most common specimens and sample treatments/analysis procedures (related to LC-MS/MS) that have been reported during the last ten years. As a final goal, we intend to provide a critical overview and suggest analytical recommendations for the establishment of suitable analytical strategies in DFSA cases.

Concentrations of citalopram and escitalopram in postmortem hair segments

Hair analysis can provide information regarding previous drug intake and use patterns, as the drugs consumed are incorporated into the hair. Therefore, reference values for drugs in hair are valuable in forensic investigations, especially when evaluating drug intake and assessing drug tolerance. The aim of the study was to determine concentrations of citalopram, escitalopram, and their primary metabolites in hair segments from deceased individuals with mental illness. Concentrations in up to six months prior to death were evaluated and compared with the estimated daily doses. Hair samples collected from 47 deceased individuals, were segmented in one to six 1 cm segments, and extracted overnight in medium. The concentrations in hair were quantified via ultra-high-performance liquid chromatography-tandem mass spectrometry. Following this quantification, the extracts were reanalyzed qualitatively using a chiral method to distinguish between citalopram and escitalopram intake. We found hair concentrations (10-90 percentile (perc.)) of citalopram from 0.12 to 67 ng/mg with a median of 8.2 ng/mg (N = 40 individuals, n = 182 segments) and of escitalopram from 0.027 to 7.0 ng/mg with a median of 3.9 ng/mg (N = 4, n = 23). The metabolite-to-drug ratios in hair (10-90 perc.) of citalopram were 0.091-0.57 with a median of 0.30 (N = 39) and of escitalopram were 0.053-0.63 with a median of 0.41 (N = 3). No correlations were found between concentrations in the hair and the estimated daily dose. However, our results indicate higher concentrations in dark hair compared to light hair, given the estimated doses, and thus an influence of hair color on the results. A significant positive correlation was found between the concentration of citalopram in the proximal segment and the blood concentrations. The median R/S-ratio of citalopram in hair was 1.5 and was similar to previously reported ratios in blood. In the present study, we report concentrations of citalopram and escitalopram in postmortem hair and their relation to an estimated daily dose and thus contribute valuable information in forensic investigations.

The Distribution of Quetiapine and 7-Hydroxyquetiapine in Guinea Pig Hair Roots and Shafts after Repeated Administration: Exploration of the Mechanism of Drug Entry and Retention in Hair

This study investigated the distribution of quetiapine and 7-hydroxyquetiapine in guinea pig hair roots and shafts after five repeated intragastric administrations at three doses (5, 10 and 25 mg/kg) by segmental analysis to explore the mechanism of drug entry and retention in hair. Hair root samples were collected after 7, 10, 14, 21, 28 and 35 d in area A after the first dose, and a hair shaft was plucked 35 d after the first dose. The maximum concentrations of quetiapine in hair roots in the low-, medium- and high-dose groups occurred at 50, 74 and 98 h after the first administration, and the maximum concentrations were 0.71 ng/mg (range: 0.54-0.84 ng/mg), 6.72 ng/mg (range: 4.59-9.75 ng/mg) and 12.72 ng/mg (range: 10.74-15.76 ng/mg), respectively. The maximum concentrations of 7-hydroxyquetiapine in the low-, medium- and high-dose groups were 0.67 ng/mg (0.23-1.15 ng/mg), 1.07 ng/mg (0.44-1.19 ng/mg) and 3.92 ng/mg (0.656.14 ng/mg), respectively, at 26 h. The maximum concentrations of quetiapine and 7-hydroxyquetiapine in hair roots were significantly positively correlated with the dose (n = 18; r2 = 0.84; P < 0.0001 for quetiapine and n = 18; r2 = 0.61; P = 0.0001 for 7-hydroxyquetiapine). The concentrations of quetiapine and 7-hydroxyquetiapine in hair roots were higher than those in hair shafts 10 d after administration, indicating drug and metabolite entry into the hair through the roots in the first few days after administration. The highest concentrations of quetiapine in the hair shaft in the low-, medium- and high-dose groups were found at the hair ends, and 7-hydroxyquetiapine in the hair shaft showed no obvious peak concentration. Combined with previous studies, we think, by analyzing the drug concentrations in the hair roots and shaft, that the most important way for drugs to enter into and be retained in hair is that the drug enters the hair through the blood circulation from hair root, then spreads and redistributes as the hair grows.

Identification of furosemide in hair in a post-mortem case by UHPLC-MS/MS with guidance on interpretation

Testing for drugs in hair raises several difficulties. Among them is the interpretation of the final concentration(s). In a post-mortem case, analyses revealed the presence of furosemide (12 ng/mL) in femoral blood, although it was not part of the victim's treatment. The prosecutor requested our laboratory to undertake an additional analysis in hair to obtain information about the use of furosemide. A specific method was therefore developed and validated to identify and quantify furosemide in hair by UHPLC-MS/MS. After decontamination of 30 mg of hair, incubation in acidic condition, extraction with ethyl acetate, the samples were analyzed by UHPLC-MS/MS. Furosemide was found in the victim's hair at 225 pg/mg. However, it was not possible to interpret this concentration due to the absence of data in the literature. Therefore, the authors performed a controlled study in two parts. In order to establish the basis of interpretation, several volunteers were tested (four after a single 20 mg administration and twenty-four under daily treatment). The first part indicated that a single dose is not detectable in hair using our method. The second part demonstrated concentrations ranging from 5 to 1110 pg/mg with no correlation between dosage and hair concentrations. The decedent's hair result was interpreted as repeated exposures. In the case of furosemide analysis, hair can provide information about its presence but cannot give information about dosage or frequency of use.

Interpol review of toxicology 2016-2019

This review paper covers the forensic-relevant literature in toxicology from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20.Papers%202019.pdf.

The Difficult Interpretation of a Hair Test Result from a 32-Month-Old Child: Administration of Propranolol and Quetiapine or Contamination?

A 23-month-old boy was brought to a medical center by his mother, as she noticed that the father has gripped him around the neck and this had left marks. As a result of this, a child protection medical examination was requested. However, there was a significant chronology of mental health issues in the mother. Among the mother’s medications, quetiapine and propranolol were the more active. Given a consultant pediatrician was concerned that the boy was vulnerable and potentially has experienced neglect and physical harm, the local authority instructed a hair test to document possible poisoning. However, this occurred several months later, due to court delays (postponed hearings and decisions) when the child was 32-month old. The laboratory received a strand of hair of the child (12 cm in length, light brown in color) and a strand of hair of the mother (&gt;20 cm in length, dark in color) with the request to test both specimens by segmentation (12 x 1 cm) for quetiapine, an anti-psychotic drug and propranolol, a β-blocker agent. After decontamination and segmentation, the specimens were incubated in borate buffer pH 9.5 and extracted by a mixture of ether/dichloromethane/hexane/isoamyl alcohol to test for the drugs, including norquetiapine by a specific LC–MS-MS method. The first 3 cm segments of the child’s hair were free of drug, roughly corresponding to the period he was no more in contact with the mother. Propranolol tested positive in the other segments at 15–72 pg/mg, with a linear increase from the proximal to the distal end. This was also observed for quetiapine, with concentrations in the range 10–18 pg/mg. Norquetiapine was never identified in the child’s hair. The following concentrations were observed in the mother’s hair: 6028–10,284, 910–4576 and 1116–6956 pg/mg for propranolol, quetiapine and norquetiapine, respectively. This confirmed that the donor was a long-term repetitive user of propranolol and quetiapine. The hair test results have indicated that the child was in contact with propranolol and quetiapine for a long period. It is not possible to put a temporal period for each segment, as the hair growth at the age of 32 months is not the same as for an adult (difference in the duration of the anagen period), nor to put any quantitative dosage or frequency of exposure(s) when interpreting the data. An increase of concentrations from root to tip was observed which is considered highly indicative of external contamination, with the older hair segments (those which are the more concentrated) being in contact for a longer time with contaminated items (hands of the mother, home items such as furniture, dishes, beddings, etc.). Overinterpreting drug findings in hair can have very serious legal implications in child protection cases, particularly when no other toxicological test and no clinical report exist to support voluntary administration of drugs. Whatever the findings, a proper interpretation of hair test results is critical and should be done ideally with other information available, such as medical history, witness statements and the available circumstances of the matter. A single hair test should not be used to determine long-term exposure to a drug.

Concentrations of Antidepressants, Antipsychotics, and Benzodiazepines in Hair Samples from Postmortem Cases

Certain postmortem case constellations require intensive investigation of the pattern of drug use over a long period before death. Hair analysis of illicit drugs has been investigated intensively over past decades, but there is a lack of comprehensive data on hair concentrations for antidepressants, antipsychotics, and benzodiazepines. This study aimed to obtain data for these substances. A LC-MS/MS method was developed and validated for detection of 52 antidepressants, antipsychotics, benzodiazepines, and metabolites in hair. Hair samples from 442 postmortem cases at the Institute of Legal Medicine of the Charité-University Medicine Berlin were analyzed. Postmortem hair concentrations of 49 analytes were obtained in 420 of the cases. Hair sample segmentation was possible in 258 cases, and the segments were compared to see if the concentrations decreased or increased. Descriptive statistical data are presented for the segmented and non-segmented cases combined (n = 420) and only the segmented cases (n = 258). An overview of published data for the target substances in hair is given. Metabolite/parent drug ratios were investigated for 10 metabolite/parent drug pairs. Cases were identified that had positive findings in hair, blood, urine, and organ tissue. The comprehensive data on postmortem hair concentrations for antidepressants, antipsychotics, and benzodiazepines may help other investigators in their casework. Postmortem hair analysis results provide valuable information on the drug intake history before death. Pattern changes can indicate if drug intake stopped or increased before death. Results should be interpreted carefully and preferably include segmental analysis and metabolite/parent drug ratios to exclude possible contamination.

Distribution pattern of common drugs of abuse, ethyl glucuronide, and benzodiazepines in hair across the scalp

While hair analysis is important and accepted in forensic applications, fundamental knowledge gaps still exist, exacerbated by a lack of knowledge of the incorporation mechanisms of substances into hair. The influence of the hair sampling location on the head on ethyl glucuronide (EtG) and cocaine concentrations was investigated by measuring the complete scalp hair of 14 (2 EtG, 4 cocaine, 8 both EtG and cocaine) study participants in a grid pattern for EtG, drugs of abuse, and benzodiazepines. Head skin perfusion and sweating rates were investigated to rationalize the concentration differences. For EtG, ratios between maximum and minimum concentrations on the scalp ranged from 2.5 to 7.1 (mean 4.4). For cocaine, the ratios ranged from 2.8 to 105 (mean 17.6). EtG concentrations were often highest at the vertex, but the distribution was strongly participant dependent. Cocaine and its metabolites showed the lowest concentrations at the vertex and the highest on the periphery, especially at the forehead. These differences led to hair from some head parts being clearly above conventional cut-offs and others clearly below. In addition to EtG and cocaine, the distributions of 24 other drugs of abuse and benzodiazepines/z-substances and metabolites are described. No clear pattern was observed for the head skin perfusion. Sweating rate measurements revealed higher sweating rates on the periphery of the haircut. Therefore, sweat could be a main incorporation route for cocaine. Concentration differences can lead to different interpretations depending on the sampling site. Therefore, the results are highly relevant for routine forensic hair analysis.

Hair Metabolomics in Animal Studies and Clinical Settings

Metabolomics is a powerful tool used to understand comprehensive changes in the metabolic response and to study the phenotype of an organism by instrumental analysis. It most commonly involves mass spectrometry followed by data mining and metabolite assignment. For the last few decades, hair has been used as a valuable analytical sample to investigate retrospective xenobiotic exposure as it provides a wider window of detection than other biological samples such as saliva, plasma, and urine. Hair contains functional metabolomes such as amino acids and lipids. Moreover, segmental analysis of hair based on its growth rate can provide information on metabolic changes over time. Therefore, it has great potential as a metabolomics sample to monitor chronic diseases, including drug addiction or abnormal conditions. In the current review, the latest applications of hair metabolomics in animal studies and clinical settings are highlighted. For this purpose, we review and discuss the characteristics of hair as a metabolomics sample, the analytical techniques employed in hair metabolomics and the consequence of hair metabolome alterations in recent studies. Through this, the value of hair as an alternative biological sample in metabolomics is highlighted.

Segmental Analysis of Chlorprothixene and Desmethylchlorprothixene in Postmortem Hair

Analysis of drugs in hair differs from their analysis in other tissues due to the extended detection window, as well as the opportunity that segmental hair analysis offers for the detection of changes in drug intake over time. The antipsychotic drug chlorprothixene is widely used, but few reports exist on chlorprothixene concentrations in hair. In this study, we analyzed hair segments from 20 deceased psychiatric patients who had undergone chronic chlorprothixene treatment, and we report hair concentrations of chlorprothixene and its metabolite desmethylchlorprothixene. Three to six 1-cm long segments were analyzed per individual, corresponding to ~3-6 months of hair growth before death, depending on the length of the hair. We used a previously published and fully validated liquid chromatography-tandem mass spectrometry method for the hair analysis. The 10th-90th percentiles of chlorprothixene and desmethylchlorprothixene concentrations in all hair segments were 0.05-0.84 ng/mg and 0.06-0.89 ng/mg, respectively, with medians of 0.21 and 0.24 ng/mg, and means of 0.38 and 0.43 ng/mg. The estimated daily dosages ranged from 28 mg/day to 417 mg/day. We found a significant positive correlation between the concentration in hair and the estimated daily doses for both chlorprothixene (P = 0.0016, slope = 0.0044 [ng/mg hair]/[mg/day]) and the metabolite desmethylchlorprothixene (P = 0.0074). Concentrations generally decreased throughout the hair shaft from proximal to distal segments, with an average reduction in concentration from segment 1 to segment 3 of 24% for all cases, indicating that most of the individuals had been compliant with their treatment. We have provided some guidance regarding reference levels for chlorprothixene and desmethylchlorprothixene concentrations in hair from patients undergoing long-term chlorprothixene treatment.