Case report and review of clenbuterol cardiac toxicity

Asthma and COPD: A Focus on β-Agonists - Past, Present and Future

Asthma has been recognised as a respiratory disorder for millennia and the focus of targeted drug development for the last 120 years. Asthma is one of the most common chronic non-communicable diseases worldwide. Chronic obstructive pulmonary disease (COPD), a leading cause of morbidity and mortality worldwide, is caused by exposure to tobacco smoke and other noxious particles and exerts a substantial economic and social burden. This chapter reviews the development of the treatments of asthma and COPD particularly focussing on the β-agonists, from the isolation of adrenaline, through the development of generations of short- and long-acting β-agonists. It reviews asthma death epidemics, considers the intrinsic efficacy of clinical compounds, and charts the improvement in selectivity and duration of action that has led to our current medications. Important β2-agonist compounds no longer used are considered, including some with additional properties, and how the different pharmacological properties of current β2-agonists underpin their different places in treatment guidelines. Finally, it concludes with a look forward to future developments that could improve the β-agonists still further, including extending their availability to areas of the world with less readily accessible healthcare.

Clenbuterol-induced myocarditis in a young man desiring to lose weight

A young man in his late 20s was presented with acute chest pain, concave ST elevation in lateral and inferior leads on ECG and elevated cardiac troponin. A thorough clinical history was notable for clenbuterol abuse. Transthoracic echocardiography revealed a small area of hypokinesia in the inferior wall and cardiac magnetic resonance supported the diagnosis of acute myocarditis revealing signs of myocardial oedema and subepicardial delayed enhancement. The patient was managed conservatively and had an uneventful clinical course. Awareness of the possibility of clenbuterol myocardial toxicity in young men admitted due to chest pain is essential to prompt diagnosis and management of this condition.

Extracellular and intracellular zilpaterol and clenbuterol quantification in Hep G2 liver cells by UPLC-PDA and UPLC-MS/MS

Zilpaterol and Clenbuterol are β-adrenergic agonists that have been widely used to feed cattle. Although the use of Zilpaterol has been approved, Clenbuterol is still used illegally at unknown doses. However, the research of both substances has been based mainly on the evaluation of residues. To our knowledge, this is the first time that a cellular model using Hep G2 cells treated with Zilpaterol and Clenbuterol is presented as an alternative approach to quantify both drugs at the cellular level. Thus, a complete analytical methodology has been developed for the accurate quantitation of these β-adrenergic agonists in both cellular compartments. We propose the use of ultra-performance liquid chromatography with photodiode array detector (UPLC-PDA) for extracellular determinations while UPLC coupled to a tandem mass spectrometer (UPLC-MS/MS) for intracellular analysis. The methods were fully validated in terms of selectivity, linearity, accuracy, and precision, limits of detection and quantitation (LOD and LOQ, respectively), stability, carryover, and matrix effect. The method for intracellular content was linear ranging from 0.25 to 8 ng/mL while for extracellular content, the concentration of Zilpaterol and Clenbuterol ranged from 0.125 to 4 μg/mL, with correlation coefficients of R > 0.98 and >0.99, respectively. The combination of the two methodologies in the cellular model showed intracellular concentrations of 0.344 ± 0.06 μg/mL and 2.483 ± 0.36 μg/mL for Zilpaterol and Clenbuterol, respectively. Extracellular concentration was 0.728 ± 0.14 μg/mL and 0.822 ± 0.11 μg/mL for Zilpaterol and Clenbuterol, respectively. This work shows the potential applications of cellular modelling in the study of toxicity for the mentioned drugs.

Clenbuterol-Induced Myocarditis: A Case Report

Objective

We present a case of a 22-year-old bodybuilder diagnosed with myocarditis secondary to clenbuterol use.

Results

The patient was primarily managed conservatively by the discontinuation of clenbuterol and the temporary use of dual anti-platelets, beta-blockers and nitrates.

Conclusion

Clenbuterol is a long-acting beta-2 agonist primarily used in veterinary medicine. In recent years, it has been illegally marketed as a weight loss supplement because of its anabolic properties and is popular among fitness enthusiasts. It is our aim to use this case to underscore the adverse effects of this drug with hopes that tighter regulations will be instituted to stem its illegal distribution.

LEARNING POINTS

Clenbuterol is primarily a veterinary drug with bronchodilator and tocolytic properties.It is illegally used as a performance enhancer by athletes and bodybuilders because of its anabolic properties.Clenbuterol misuse can result in myocardial injury.

Survey of clenbuterol in bovine muscle and liver in Ecuador

Clenbuterol is a steroid-type drug used in respiratory treatments in both humans and animals. However, it has a secondary effect related to the hypertrophy process in muscle and fat reduction. The illegal or bad use of clenbuterol has been reported in several countries, but there is scarce information in South America, where the production and consumption of meat are considerable. In this sense, the present study aimed at evaluating the occurrence of clenbuterol in bovine muscle and liver samples from a high cattle production area of Ecuador in 2015 and 2018. For this purpose, 57-58 samples were evaluated in 2015 and 20 samples in 2018 using the Enzyme-Linked Inmuno Sorbent Assay and ultrahigh-performance liquid chromatography-tandem mass spectrometry. The results showed complained results for clenbuterol in meat samples from both years and 23% (2015) and 85% (2018) of the samples of meat complied the maximum residue level defined by CODEX.

Complete Post-mortem Investigations in a Death Involving Clenbuterol After Long-term Abuse

The body of a 61-year-old man was found at his home by his wife, lying on the floor, near the bathroom, around midnight. He was known to be training for bodybuilding, using anabolic steroids. Police investigations revealed the presence of two types of tablets at home, one supposed to contain clenbuterol (0.040 mg) and the other stanozolol (10 mg). Testing the tablets revealed different dosages from what was expected, i.e., 0.073 and 11.5 mg/tablet, for clenbuterol and stanozolol, respectively. External body examination and autopsy, which was performed the next day, revealed generalized organ congestion and lack of any traumatic injury (confirmed by radiology). Cardiomegaly, with a heart weighing 692 g, was obvious. Anatomic pathology tests did not reveal evidence of malformations, but atheromatous plaque was identified in the coronaries during complete histology investigations. Femoral blood, urine, bile, gastric contents and two strands of hair (6 cm) were collected for toxicology. These specimens were submitted to standard analyses, but also to a specific LC-MS-MS method for clenbuterol and stanozolol testing. Clenbuterol was identified in all the tissues, including femoral blood (1.1 ng/mL), urine (7.2 ng/mL), bile (2.4 ng/mL), gastric content (3.2 ng/mL) and hair (23 pg/mg). Stanozolol only tested positive in hair (11 pg/mg). All other analyses were negative, including blood alcohol and drugs of abuse. The pathologists concluded to cardiac insufficiency with support of cardiomegaly, in a context involving repetitive abuse of anabolic drugs. This case indicates that more attention should be paid to clenbuterol, a drug widely used as a stimulant by people who want to lose weight, athletes and bodybuilding practitioners.

Death of an apprentice bodybuilder following 2,4-dinitrophenol and clenbuterol intake

We present the case of a 17-year-old man, who died after 2,4-dinitrophenol (DNP) and clenbuterol consumption, which he likely took for physical enhancement. Forensic post-mortem examination revealed a yellowish skin colour and nonspecific signs of asphyxia. Analytical confirmation of the intoxication was obtained in blood and urine, with high levels of DNP and clenbuterol. Both of these substances are used by bodybuilders as DNP enhance lipolysis and clenbuterol has anabolic properties, but their toxicity is underestimated. DNP uncouples oxidative phosphorylation, leading to thermogenesis and even relatively small doses can cause fatal hyperthermia. Clenbuterol is a β2 agonist that causes electrolyte disturbances (hypokalemia and hyperglycemia mostly) and death have been described through coronary vasospasm. Given the circumstances in which the body was found and toxicological results, we believe the cause of death to be fatal hyperthermia from DNP intake. These substances are illegal in many countries, but easily bought online. Through this availability, the last decades have seen an increase of fatal intoxications. Websites selling them are regularly closed by French public authorities and Interpol, but unfortunately it seems insufficient.

Quantification and Stereochemical Composition of R-(−) and S-(+)-Clenbuterol Enantiomers in Bovine Urine by Liquid Chromatography–Tandem Mass Spectrometry

Clenbuterol (4-amino-α-[(tert-butylamino)methyl]-3,5-dichlorobenzylalcohol) is a β2-adrenergic agonist. The consumption of meat contaminated with clenbuterol can lead to increased heart rate, blood pressure, anxiety, palpitations and skeletal muscle tremors. Several analytical methods have been developed to identify and quantify clenbuterol in different biological matrices. In this report, we have developed a specific and sensitive analytical method for quantifying clenbuterol and performed an in-depth enantiomeric analysis in bovine urine. The method was evaluated in accordance with international guidelines, and we used an isotopically labeled analog as an internal standard. The extraction efficiency for clenbuterol in bovine urine was > 98%, the limit of detection was 0.05 ng/mL and the limit of quantification was 0.10 ng/mL. Our assay showed high specificity, no carryover was observed and the assay was linear in the range 0.10–8.0 ng/mL. Fifteen bovine urine samples were analyzed (containing clenbuterol), and an enantiomeric analysis was performed. The clenbuterol concentration range was 0.10–10.56 ng/mL across these samples. The levorotatory enantiomer was detected at greater concentrations than the dextrorotatory enantiomer, the ratio being 1.7 ± 0.6 (n = 15), and a statistical difference was observed (P < 0.05) using the Wilcoxon test.

Abuse of Prescription Drugs in the Context of Novel Psychoactive Substances (NPS): A Systematic Review

Recently, a range of prescription and over-the-counter drugs have been reportedly used as Novel Psychoactive Substances (NPS), due to their potential for abuse resulting from their high dosage/idiosyncratic methods of self-administration. This paper provides a systematic review of the topic, focusing on a range of medications which have emerged as being used recreationally, either on their own or in combination with NPS. Among gabapentinoids, pregabalin may present with higher addictive liability levels than gabapentin, with pregabalin being mostly identified in the context of opioid, polydrug intake. For antidepressants, their dopaminergic, stimulant-like, bupropion activities may explain their recreational value and diversion from the therapeutic intended use. In some vulnerable clients, a high dosage of venlafaxine (‘baby ecstasy’) is ingested for recreational purposes, whilst the occurrence of a clinically-relevant withdrawal syndrome may be a significant issue for all venlafaxine-treated patients. Considering second generation antipsychotics, olanzapine appears to be ingested at very large dosages as an ‘ideal trip terminator’, whilst the immediate-release quetiapine formulation may possess proper abuse liability levels. Within the image- and performance- enhancing drugs (IPEDs) group, the beta-2 agonist clenbuterol (‘size zero pill’) is reported to be self-administered for aggressive slimming purposes. Finally, high/very high dosage ingestion of the antidiarrhoeal loperamide has shown recent increasing levels of popularity due to its central recreational, anti-withdrawal, opiatergic effects. The emerging abuse of prescription drugs within the context of a rapidly modifying drug scenario represents a challenge for psychiatry, public health and drug-control policies.

A Case Series of Clenbuterol Toxicity Caused by Adulterated Heroin

BACKGROUND

Adulteration of drugs of abuse may be done to increase profits. Some adulterants are relatively innocuous and others result in significant toxicity. Clenbuterol is a β2-adrenergic agonist with veterinary uses that has not been approved by the U.S. Food and Drug Administration for human use. It is an infrequently reported heroin adulterant. We describe a cluster of hospitalized patients with laboratory-confirmed clenbuterol exposure resulting in serious clinical effects.

CASE SERIES

Ten patients presented with unexpected symptoms shortly after heroin use. Seven evaluated by our medical toxicology service are summarized. Presenting symptoms included chest pain, dyspnea, palpitations, and nausea/vomiting. All patients were male, with a median age of 40 years (interquartile range [IQR] 38-46 years). Initial vital signs included a heart rate of 120 beats/min (IQR 91-137 beats/min), a respiratory rate of 20 breaths/min (IQR 18-22 breaths/min), a temperature of 36.8°C (IQR 36.7-37.0°C), a systolic blood pressure of 107 mm Hg (IQR 91-131 mm Hg), and a diastolic blood pressure of 49 mm Hg (IQR 40-70 mm Hg). Serum potassium nadir was 2.5 mEq/L (IQR 2.2-2.6 mEq/L), initial glucose was 179 mg/dL (IQR 125-231 mg/dL), initial lactate was 9.4 mmol/L (IQR 4.7-10.5 mmol/L), and peak creatine phosphokinase was 953 units/L (IQR 367-10,363 units/L). The median peak troponin level in six patients was 0.7 ng/mL (IQR 0.3-2.4 ng/mL). Three patients underwent cardiac catheterization and none had significant coronary artery disease. Clenbuterol was detected in all patients after comprehensive testing. All patients survived with supportive care. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Atypical presentations of illicit drug intoxication may raise concern for drug adulteration. In the case of heroin use, the presence of adrenergic symptoms or chest pain with hypokalemia, lactic acidosis, and hyperglycemia suggests adulteration with a β-agonist, such as clenbuterol, and patients presenting with these symptoms often require hospitalization.