Determination of γ-hydroxybutyrate (GHB), β-hydroxybutyrate (BHB), pregabalin, 1,4-butane-diol (1,4BD) and γ-butyrolactone (GBL) in whole blood and urine samples by UPLC-MSMS

Development and validation of a multiplexed LC-MS/MS ketone body assay for clinical diagnostics

Objectives

Ketone bodies (KBs) serve as important energy sources that spare glucose, providing the primary energy for cardiac muscle, skeletal muscle during aerobic exercise, and the brain during periods of catabolism. The levels and relationships between the KBs are critical indicators of metabolic health and disease. However, challenges in separating isomeric KBs and concerns about sample stability have previously limited their clinical measurement.

Methods

A novel 6.5-minute liquid chromatography-mass spectrometry-based assay was developed, enabling the precise measurement of alpha-, beta- and gamma-hydroxybutyrate, beta-hydroxyisobutyrate, and acetoacetate. This method was fully validated for human serum and plasma samples by investigating extraction efficiency, matrix effects, accuracy, recovery, intra- and inter-precision, linearity, lower limit of quantitation (LLOQ), carryover, specificity, stability, and more. From 107 normal samples, reference ranges were established for all analytes and the beta-hydroxybutyrate/acetoacetate ratio.

Results

All five analytes were adequately separated chromatographically. An extraction efficiency between 80 and 120 % was observed for all KBs. Accuracy was evaluated through spike and recovery using 10 random patient samples, with an average recovery of 85-115 % for all KBs and a coefficient of variation of ≤ 3 %. Coefficients of variation for intra- and inter-day imprecision were < 5 %, and the total imprecision was < 10 %. No significant interferences were observed. Specimens remained stable for up to 6 h on ice or 2 h at room temperature.

Conclusions

The developed method is highly sensitive and robust. It has been validated for use with human serum and plasma, overcoming stability concerns and providing a reliable and efficient quantitative estimation of ketone bodies.

Gamma-hydroxybutyrate (GHB), 1,4-butanediol (1,4BD), and gamma-butyrolactone (GBL) intoxication: A state-of-the-art review

γ-hydroxybutyrate (GHB) is synthesized endogenously from γ-aminobutyric acid (GABA) or exogenously from 1,4-butanediol (butane-1,4-diol; 1,4-BD) or γ-butyrolactone (GBL). GBL, and 1,4-BD are rapidly converted to GHB. The gastric absorption time, volume of distribution, and half-life of GHB are between 5 and 45 min, 0.49 ± 0.9 L/kg, and between 20 and 60 min, respectively. GHB and its analogues have a dose-dependent effect on the activation of GHB receptor, GABA-B, and GABA localized to the central nervous system. After ingestion, most patients present transient neurological disorders (lethal dose: 60 mg/kg). Chronic GHB consumption is associated with disorders of use and a withdrawal syndrome when the consumption is discontinued. GHB, GBL, and 1,4-BD are classified as narcotics but only the use of GHB is controlled internationally. They are used for drug facilitated (sexual) assault, recreational purposes, slamsex, and chemsex. To confirm an exogenous intake or administration of GHB, GBL, or 1-4-BD, the pre-analytical conservation is crucial. The antemortem cutoff doses for detection are 5 and 5-15 mg/L, with detection windows of 6 and 10 h in the blood and urine, respectively Control of GHB is essential to limit the number of users, abuse, associated risks, and death related to their consumption.

Magnetic covalent-organic frameworks for the simultaneous extraction of eleven emerging aromatic disinfection byproducts in water samples coupled with UHPLC-MS/MS determination

A simple method based on magnetic solid-phase extraction (MSPE) was developed for the simultaneous extraction of eleven emerging aromatic disinfection byproducts (DBPs) in water samples coupled with ultrahigh-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) determination. A magnetic covalent-organic framework (COF) material, namely, Fe₃O₄ @TpBD, was facilely synthesized and fully characterized, followed by an MSPE process. Several important MSPE parameters, such as the magnetic ratio, Fe₃O₄ @TpBD amount and sample pH, were systematically investigated. Under optimal conditions, the limits of detection and quantification of this COF-MSPE-UHPLC-MS/MS method were as low as 0.07-1.81 ng/L and 0.24-5.99 ng/L, respectively. Good precision was obtained with relative standard deviations (RSDs) of 1.3-10.9% (intraday) and 4.3-15.9% (interday). Furthermore, the validated method was proven applicable to real water samples; for example, the recoveries were 86.8-115.1% for the secondary effluent, and several DBPs in swimming pool water were detected. Notably, the MSPE process required only 7 min, ensuring that the DBPs were relatively stable during the whole analysis process and that Fe₃O₄ @TpBD demonstrated excellent reusability. The COF-based MSPE method with simplicity, rapidity and efficiency provided an ideal sample pretreatment alternative to determine trace DBPs in complex matrices.

Date-rape evidence through fast determination of γ-butyrolactone in adulterated beverages

An infrared spectroscopy (IR) based methodology has been developed to determine γ-butyrolactone (GBL) in adulterated beverages. The proposed method permits the direct screening of GBL in beverages and involves a minimum sample treatment requiring less than 2 min for quantitative determination of GBL. Sensitivity of IR method was improved by using liquid-liquid extraction (LLE) providing detection limits of 0.023 mg g^-1. Accuracy of the proposed methodology was evaluated through the analysis of soft beverages and alcoholic cocktails spiked with GBL at concentration levels ranging from 0.075 to 10 mg g^-1 providing recovery values from 91 to 100%. GBL was determined in twelve blind-spiked beverages, including from mineral water to wine and cocktails. Results obtained were statistically comparable to those provided by a liquid chromatography (LC) reference methodology and consistent with the spiked values. Therefore, the use of LLE-FTIR allowed a simple, sensitive and quantitative determination of GBL in soft beverages and alcoholic cocktails, thus evidencing its use for sex submission intention.

Signal Separated Quantification of γ-Hydroxybutyrate With Liquid Chromatography-Tandem Mass Spectrometry in Human Urine and Serum as an Improvement of the Analyte Adduct Ion Based Quantification

The aim of the work was the development and validation of an LC-MS/MS γ-hydroxybutyrate (GHB) quantification method in urine and human serum by the use of the analyte adduct ion formation strategy. A combined detection with a conventional precursor ion in the negative electrospray mode and additionally GHB adduct ions with both sodium acetate and lithium acetate was in focus. Therefore GHB quantification based on separated MS/MS signals. Two tandem mass spectrometers representing different MS/MS generations (Sciex API 4000 QTrap and Sciex API 5500 QTrap) were used for method validation and comparison. Shimadzu HPLC Systems equipped with a Luna 5 µm C18 (2) 100 A, 150 mm × 2 mm analytical column were applied successfully for sample analyses. Infusion experiments were performed for adduct identification and analyte detection optimisation. Sample preparation could be limited to a simple and fast protein precipitation/sample dilution. An effective signal separated GHB quantification with three independent precursor ions representing separated areas of the mass spectrum was developed, validated according to forensic guidelines and applied in the routine. The developed and applied strategy resulted in a higher safety factor for the analyte quantification performed in the forensic toxicology. A relevant analytical improvement could be achieved with this alternative adduct based GHB analysis since a good correlation of analyte concentrations calculated on the basis of separated signals was stated as useful analytical information.

Derivatization of γ-Amino Butyric Acid Analogues for Their Determination in the Biological Samples and Pharmaceutical Preparations: A Comprehensive Review

γ-Aminobutyric acid (GABA) plays an important role in regulating neuronal excitability. Four structurally related drugs to GABA including pregabalin (PGB), gabapentin (GBP), vigabatrin (VGB), and baclofen are used for the treatment of central nervous system disorders. These drugs are small aliphatic molecules having neither fluorescent nor strong absorbance in the ultraviolet/visible region; therefore, direct determination of these analytes by optical methods is difficult. Additionally, their high boiling point makes gas chromatography impossible. Accordingly, the amine or acid moiety in these drugs is derivatized in order to improve their selectivity and sensitivity during determination in the biological samples. This review focuses on derivatization based methods and their different reactions for determination of PGB, GBP, VGB, and baclofen in the biological samples and pharmaceutical preparations reported between 1980 and 2020. High-performance liquid chromatography methods coupled with different detectors are a commonly used methods for determination of GABA analogs after derivatization. These methods cover 38.89% of all developed methods for determination of GABA analogs.

Relationship between betahydroxybutyrate (BHB) and acetone concentrations in postmortem blood and cause of death

Unexpected death caused by diabetic or alcoholic ketoacidosis is easily overlooked due to the non-specific symptoms. Although the acid betahydroxybutyrate (BHB) is the most abundant ketone body formed in conditions with ketoacidosis, routine analysis in postmortem investigations often only includes the neutral ketone body acetone. This study aims to evaluate the usefulness of implementing routine BHB analysis in postmortem cases, by investigating the relationship between BHB and acetone concentrations in postmortem blood and the main cause of death. From our database of forensic autopsy cases examined from 2012 to 2015, there were 376 cases with BHB and/or acetone detected in postmortem blood that could be paired with data from the Norwegian Cause of Death Registry. Cases were categorized into three groups based on cause of death: "Diabetes-related" (n = 38), "Alcohol-related" (n = 35) and "Other" (n = 303). Analysis of BHB in blood was performed using UHPLC-MS/MS (limit of quantification (LOQ) 52 mg/L) and of acetone using HS-GC-FID (LOQ 87 mg/L). For the purpose of the study, the acetone method was also validated for a LOQ of 23 mg/L. The median BHB concentration was significantly higher in the group of diabetes-related deaths (671 mg/L, range 68-1311 mg/L) compared to the group of alcohol-related (304 mg/L, range 65-1555 mg/L, p <0.001) and other causes of deaths (113 mg/L, range 0-1402 mg/L, p <0.001). In seven deaths (1.9%), the BHB blood concentration was above the suggested pathological threshold of 250 mg/L, without detection of acetone in blood above 23 mg/L. In 15% of deaths by other causes than diabetes or alcohol, a pathologically significant BHB blood concentration was detected. Our results indicate that BHB is a more reliable marker of pathologically significant ketoacidosis than acetone, and we suggest that BHB should be routinely analyzed in postmortem investigations.

Metabolic Alterations Associated with γ-Hydroxybutyric Acid and the Potential of Metabolites as Biomarkers of Its Exposure

γ-Hydroxybutyric acid (GHB) is an endogenous short chain fatty acid that acts as a neurotransmitter and neuromodulator in the mammalian brain. It has often been illegally abused or misused due to its strong anesthetic effect, particularly in drug-facilitated crimes worldwide. However, proving its ingestion is not straightforward because of the difficulty in distinguishing between endogenous and exogenous GHB, as well as its rapid metabolism. Metabolomics and metabolism studies have recently been used to identify potential biomarkers of GHB exposure. This mini-review provides an overview of GHB-associated metabolic alterations and explores the potential of metabolites for application as biomarkers of GHB exposure. For this, we discuss the biosynthesis and metabolism of GHB, analytical issues of GHB in biological samples, alterations in metabolic pathways, and changes in the levels of GHB conjugates in biological samples from animal and human studies. Metabolic alterations in organic acids, amino acids, and polyamines in urine enable discrimination between GHB-ingested animals or humans and controls. The potential of GHB conjugates has been investigated in a variety of clinical settings. Despite the recent growth in the application of metabolomics and metabolism studies associated with GHB exposure, it remains challenging to distinguish between endogenous and exogenous GHB. This review highlights the significance of further metabolomics and metabolism studies for the discovery of practical peripheral biomarkers of GHB exposure.

Determination of ketone bodies in biological samples via rapid UPLC-MS/MS

Efforts to enhance wellness and ameliorate disease via nutritional, chronobiological, and pharmacological interventions have markedly intensified interest in ketone body metabolism. The two ketone body redox partners, acetoacetate (AcAc) and D-β-hydroxybutyrate (D-βOHB) serve distinct metabolic and signaling roles in biological systems. A highly efficient, specific, and reliable approach to simultaneously quantify AcAc and D-βOHB in biological specimens is lacking, due to challenges of separating the structural isomers and enantiomers of βOHB, and to the chemical instability of AcAc. Here we present a single UPLC-MS/MS method that simultaneously quantifies both AcAc and βOHB using independent stable isotope internal standards for both ketones. This method incorporates one sample preparation step requiring only 7 min of analysis per sample. The output is linear over three orders of magnitude, shows very low limits of detection and quantification, is highly specific, and shows favorable recovery yields from mammalian serum and tissue samples. Tandem MS discriminates D-βOHB from structural isomers 2- or 4-hydroxybutyrate as well as 3-hydroxyisobutyrate (3-HIB). Finally, a simple derivatization distinguishes D- and L-enantiomers of βOHB, 3-HIB, and 2-OHB, using the same rapid chromatographic platform. Together, this simple, efficient, reproducible, scalable, and all-encompassing method will support basic and clinical research laboratories interrogating ketone metabolism and redox biochemistry.

A Critical Review on Analytical Methods for Recently Approved FDC Drugs: Pregabalin and Etoricoxib

Fixed-dose combinations (FDCs) refer to products containing two or more active ingredients combined in a single dosage form. The FDCs are justified because of several advantages. These are a) potentiating therapeutic efficacy, b) reducing the incidences of adverse drug effects, c) having pharmacokinetic advantages, d) reducing pills burden, e) reducing the dose of individual drugs and f) decreasing the drug resistance development. A recently approved FDC of Pregabalin IP (75 mg) and Etoricoxib (60 mg) recommended to control neuropathic chronic back pain. Analytical methods are available for individual quantitation of pregabalin (PGB) and etoricoxib (ETC), but an effective and reliable analytical method has not been reported for their combination. Thus, the objective of this literature survey was to gather information on various analytical instrumental methods used so far for the individual quantitation of PGB and ETC in various matrices. Such data would be useful to the scientific community to develop a novel analytical method for the analysis of recently approved FDC of PGB and ETC. Various scientific databases were explored to meet the objectives, and the information is synchronized. The reported methods are high-performance liquid chromatography (48% & 53%), hyphenated techniques (54% & 21%), spectroscopy (50% & 34%), and high-performance thin-layer chromatography, or thin-layer chromatography (6% & 13%) for pregabalin and etoricoxib, respectively. All these methods were specific and selective for the analysis of individual drugs.

Simultaneous Quantification of γ-Hydroxybutyrate, γ-Butyrolactone, and 1,4-Butanediol in Four Kinds of Beverages

γ-Hydroxybutyrate (GHB) is a neurotransmitter, which exhibits a strong central nervous system depressant effect. The abuse of GHB or its precursor substances (γ-butyrolactone (GBL) and 1,4-butanediol (1,4-BD)) may cause serious problems. This study developed a fast and effective UHPLC-MS/MS method for the simultaneous quantification of GHB, GBL, and 1,4-BD in four popular beverages, including carbonated drinks, tea, apple cider vinegar, and coffee. The established method overcomes the influence of the in-source collision-induced dissociation of unstable compounds during quantification. The limits of detection were 0.2 μg/mL for GBL and 0.5 μg/mL for GHB and 1,4-BD with excellent linearity in the range of 0.2–50 μg/mL. The recoveries of the three compounds at three spiked levels (2.5, 5.0, and 10.0 μg/mL) in the four kinds of beverages studied were between 90 and 110%, while the relative standard deviations (RSDs) were all <10%. The matrix effect was negligible using this simple and appropriate preprocessed procedure. The method established in this study can quickly and reliably detect the GHB content and its analogues in beverages.

Rate of elimination of γ-hydroxybutyrate from blood determined by analysis of two consecutive samples from apprehended drivers in Norway

AIM

Gamma-hydroxybutyrate (GHB) is a common drug of abuse with an elimination half-life of 20-45 min. However, there is some evidence that GHB might exhibit saturation kinetics after ingesting high recreational doses. The aim of this study was to investigate the elimination kinetics of GHB from blood in people apprehended by the police for impaired driving and secondary to describe concentrations in all GHB-positive drivers.

METHODS

Two consecutive blood samples were taken about 30-40 min apart from N = 16 apprehended drivers in Norway. GHB was determined in blood by an Ultra High-Performance Liquid Chromatography-Tandem Mass Spectrometry (UHPLC-MS/MS) method. The changes in GHB between the two consecutive blood samples allowed estimating GHB's elimination half-life, assuming first-order and zero-order elimination kinetics. GHB concentrations are also reported for N = 1276 apprehended drivers with GHB in blood.

RESULTS

The median time interval between collecting the two blood samples was 36 min (range 20-56 min). The median concentration of GHB in the first blood sample was 56.5 mg/L (range 14.1-142 mg/L) compared with 47.8 mg/L in the second sample (range 9.75-113 mg/L). The median elimination half-life was 103 min (range 21-187 min), and GHB's median zero-order elimination rate constant was 21.0 mg/L/h (range 6.71-45.4 mg/L/h). Back-calculation to the time of driving resulted in GHB concentrations up to 820 mg/L assuming first-order kinetics and up to 242 mg/L assuming zero-order kinetics. In all drivers (N = 1276), the median GHB concentration was 73.7 mg/L and highest was 484 mg/L.

CONCLUSION

The elimination half-life of GHB in blood samples from apprehended drivers was longer than expected compared with results of controlled dosing studies. Zero-order kinetics seems a more appropriate model for GHB when concentrations are back-calculated, and the median elimination rate was 21 mg/L/h.

Gamma-hydroxybutyrate abuse: pharmacology and poisoning and withdrawal management

Gamma-hydroxybutyrate (GHB) is a central nervous system depressant primarily used as a recreational drug of abuse, but also for the treatment of narcolepsy with cataplexy in adult patients and as an adjuvant for control of alcohol withdrawal syndrome. The main aim of this review is to summarise updated knowledge about GHB pharmacokinetics and pharmacodynamics, acute poisoning, and clinical features of GHB withdrawal syndrome, its diagnosis and medical treatment. The most common clinical signs and symptoms of acute poisoning include sleepiness to deep coma, bradycardia, hypotension, and respiratory failure. Therapy is essentially supportive and based on continuous monitoring of vital signs. GHB withdrawal syndrome shares patterns with other withdrawal syndromes such as alcohol withdrawal and is sometimes difficult to distinguish, especially if toxicological tests are GHB-negative or cannot be performed. There are no official detoxification protocols for GHB withdrawal syndrome, but its therapy is based on benzodiazepine. When benzodiazepine alone is not effective, it can be combined with barbiturates or antipsychotics. Information about abuse and distribution of GHB and its precursors/analogues among the general population is still limited. Their prompt identification is therefore crucial in conventional and non-conventional biological matrices, the latter in particular, to clarify all the issues around this complex molecule.

Application of (LC/)MS/MS precursor ion scan for evaluating the occurrence, formation and control of polar halogenated DBPs in disinfected waters: A review

Water disinfection can result in the unintended formation of halogenated disinfection byproducts (DBPs), which have been the subject of intensive investigation over the past 40 years. Robust methods for evaluating and characterizing the formation of halogenated DBPs are prerequisites for ultimately controlling the formation of DBPs and ensuring quality and safe disinfected water. Only a fraction of the total organic halogen (TOX) formed during disinfection has been chemically identified or even well characterized by the classical (derivatization-)gas chromatography/mass spectrometry (GC/MS) method. Such a method may not be amenable to the detection of polar halogenated DBPs, which constitute a major portion of the TOX that is still unaccounted for. Accordingly, a novel precursor ion scan (PIS) method using (liquid chromatography/) electrospray ionization-triple quadrupole mass spectrometry was developed for the rapid selective detection of all polar halogenated DBPs-no matter whether the DBPs are known or unknown-in water. This article reviews recent literature on the application of the PIS method for evaluating the occurrence, formation and control of polar halogenated DBPs in disinfected waters. The challenges in developing the PIS method were briefly summarized. Application of the powerful method pinpointed >150 previously unknown DBPs and revealed the formation, speciation and transformation of halogenated DBPs in disinfected drinking water, wastewater effluents, and swimming pool water. For the same source water, positive correlations were found between the total ion intensity (TII) levels in the PIS spectra of m/z 35/79/126.9 and the total organic chlorine/bromine/iodine levels in the disinfected water sample, and a disinfected sample with a higher TII level generally showed a higher toxic potency. Accordingly, the TII value can be used as a surrogate to comparatively reflect the water quality and assess the efficiency of a DBP control approach. To achieve a more comprehensive and systematic understanding of the DBP compositions in different waters and thus better control the DBP formation and reduce their overall toxicity, topics for future work were discussed.

Development of a Micellar Electrokinetic Chromatographic Method with Indirect UV Detection for Pregabalin Determination in Serum Samples

Background: A micellar electrokinetic chromatographic (MEKC)/ indirect UV detection method with hydrodynamic and electrokinetic injection has been developed for the determination of pregabalin in the serum samples. Methods: Separation of the drug was achieved on Agilent capillary electrophorese in less than 5 min using a 50 cm × 75 μm i.d. uncoated fused-silica capillary and a background electrolyte (BGE) consisting of 5-aminosalicylic acid (5-ASA, 10 mmol L-1), cetyl trimethylammonium bromide (CTAB, 1 mmol L-1) and tri-sodium citrate (4% w/v). The influence of various parameters on the separation such as separation voltage, injection time, cassette temperature, pH of BGE and organic modifier was investigated. Results: Method validation shown good linearity (R2> 0.999) in the range of 1.5-100 µg mL-1 of pregabalin. A limit of detection (LOD) of 0.8 μg mL-1 and a limit of quantitation (LOQ) of 2.6 μg mL-1 were reported for pregabalin. Conclusion: The proposed method was found to be suitable and accurate for the determination of pregabalin in serum samples.

Analytical method development of methylisothiazolinone, a preservative, in rat plasma using LC-MS/MS

Methylisothiazolinone (MI) is a preservative used in consumer products to control bacterial and fungal growth. MI can be toxic, act as a skin sensitizer and irritant, and initiate lung diseases; therefore, it is important to understand the mechanisms underlying the toxicity of MI in the body. In this study, we developed a method to analyze plasma MI by using an LC-MS/MS-coupled multiple reaction monitoring (MRM) technique, which follows the fragments of a target metabolite in rat plasma. The MRM transition of MI was m/z 116 ➔ 101, and the lower limit of quantification (LLOQ) was set at 10 ng/mL. Including the concentration of LLOQ, a seven-point calibration curve explained much of the variation in the response, and it was strongly linear (R² = 0.9998); its intra- and inter-day accuracy and precision values were within 15% of the standard deviation (SD%) and along with the FDA and Korea Ministry of Food and Drug Safety guidelines. For intravenous (iv) pharmacokinetic studies of MI using rats, we developed an analytical method that was useful in detecting the profile of MI in the plasma. We also determined half-life, and area under the curve (AUC) of MI using a non-compartment model, and these might be useful for the study of toxic mechanisms of MI in the body.

A fatal blood concentration of 5-APB

For the new psychoactive drug 5-(2-aminopropyl) benzofuran (5-APB), very limited knowledge is available regarding lethal concentrations. We present a case and report the post mortem blood concentration of a fatal outcome for a 25 year old man related to the consumption of 5-APB. After intake, he became unconscious and stopped breathing. Cardiopulmonary resuscitation was started without success. After 30min he was declared dead at the scene. During autopsy, whole blood from the femoral vein was collected and screened for a wide range of medicinal drugs and drugs of abuse. 5-APB was initially identified by ultra high performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UHPLC-QTOF-MS) and subsequently confirmed by using ultra high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). The only toxicological findings were ethanol 0.6g/L, tetrahydrocannabinol (THC) 0.0024mg/L and 5-APB 0.86mg/L. The cause of death was attributed to intake of 5-APB. Only one previous report of a fatal 5-APB concentration as the main toxicological agent exist in the literature, and the present concentration indicated that 5-APB could be lethal in lower concentrations than previously reported.

A Validated Fluorometric Method for the Rapid Determination of Pregabalin in Human Plasma Applied to Patients With Pain

BACKGROUND

Pregabalin has been used for the treatment of pain. A clinically accepted method applied to patients with pain has not been published for the determination of pregabalin in human plasma. This study developed a fluorometric ultrahigh-performance liquid chromatography (UHPLC) method to measure pregabalin concentration in patients with pain.

METHODS

After plasma pretreatment involving protein precipitation, pregabalin and gabapentin as an internal standard were derivatized with 4-fluoro-7-nitrobenzofurazan (NBD-F) under the following reaction conditions: 1 minute, pH 10, and 60°C. The UHPLC separation was performed using a 2.3-μm particle size octadecylsilyl column. The fluorescence detector was set at excitation and emission wavelengths of 470 and 530 nm, respectively. The predose blood samples were collected from 40 patients with pain who have been treated with 75 mg of pregabalin twice daily.

RESULTS

The chromatographic run time was 1.25 minutes. No interfering peaks were observed in the blank plasma at the retention times of NBD derivatives. The calibration curve of pregabalin was linear at a range of 0.05-10 mcg/mL (r > 0.999). The lower limit of quantification was 0.05 mcg/mL. The intra-assay accuracy and precision were 98.3%-99.8% and within 4.3%, respectively. The inter-assay accuracy and precision were 103.2%-107.1% and within 4.1%, respectively. The predose plasma concentration of pregabalin in patients with pain ranged from 0.14 to 8.5 mcg/mL.

CONCLUSIONS

This study provides a validated fluorometric UHPLC method with fast analytical performance for the determination of pregabalin in human plasma. The present method could be applied to patients with pain and be used for the clinical research or therapeutic drug monitoring of pregabalin.

Impairment due to alcohol, tetrahydrocannabinol, and benzodiazepines in impaired drivers compared to experimental studies

OBJECTIVE

In some countries, per se laws for other drugs than alcohol are used to judge drunk and drugged drivers. These blood concentration limits are often derived from experimental studies on traffic relevant behavior of healthy volunteers. Knowledge about how results from experimental studies could be transferred to a real-life setting is missing. The aim of this study was to compare impairment seen in experimental studies to the impairment seen at equivalent concentrations in apprehended drunk and drugged drivers.

METHODS

Results from previously performed meta-analyses of experimental studies regarding impairment from alcohol, tetrahydrocannabinol (THC), and benzodiazepines were compared to impairment in apprehended drunk and drugged drivers as judged by a clinical test of impairment. Both experimental studies and real-life cases were divided into 4 groups according to increasing blood drug concentration intervals. The percentage of impaired test results in experimental studies was compared to the percentage of impaired subjects among drivers within the same blood drug concentration window.

RESULTS

For ethanol, the percentage of impaired drivers (n = 1,223) increased from 59% in the lowest drug concentration group to 95% in the highest drug concentration group, compared to 7 and 72% in the respective groups in experimental studies. For THC, the percentage of impaired drivers (n = 950) increased from 42 to 58%, the corresponding numbers being 11 and 42% for experimental studies. For benzodiazepines, the percentage of impaired drivers (n = 245) increased from 46 to 76%, the corresponding numbers being 16 and 60% for experimental studies. The increased odds ratio for impairment between 2 concentration groups was comparable for experimental studies and impaired drivers.

CONCLUSIONS

Fewer test results indicated impairment in experimental studies compared to impaired drivers in real life when influenced by similar blood concentrations of either ethanol, THC, or benzodiazepines. In addition, a comparable relationship between drug concentration and impairment was seen for both experimental studies and real-life cases. We believe that the present study strengthens the background for using experimental studies to establish fixed concentration limits for drunk and drugged drivers, but experimental studies in an impaired driver population could further expand our knowledge.

Prevalence and concentrations of drugs in older suspected drugged drivers

OBJECTIVE

Older drivers are somewhat more likely to be involved in car crashes than middle-aged drivers but less likely to be involved than younger drivers. This study aimed to assess the extent of drug use in older suspected drunk and drugged drivers, with respect to which drugs were detected and at which concentrations.

METHODS

Blood samples from older suspected drunk and drugged drivers taken between February 1, 2012, and May 22, 2013, were identified from the database at the Norwegian Institute of Public Health and were retrospectively analyzed for a broad repertoire of drugs relevant for impairment. The prevalence of different drugs among the suspected drunk and drugged drivers was studied. Regarding drug concentrations, the findings in older drivers (>65 years) were compared to a reference group of apprehended drivers aged 20-40 years.

RESULTS

Four hundred and ten older suspected drunk and drugged drivers were included. Any drug (including ethanol) was detected in 92% of blood samples, and ethanol was detected in 81%. Benzodiazepines were found in 15% of the older drivers and z-hypnotics (zopiclone or zolpidem) were detected in 13%. The most frequent single legal drugs found in blood samples taken from older impaired drivers were zopiclone (9.8%) and diazepam (9.3%). Regarding drug combinations, older drivers used a mean number of 1.4 drugs, and 20% of ethanol-positive cases showed at least one other drug. High drug concentrations of clonazepam and diazepam were more frequently seen in the younger group.

CONCLUSIONS

This study showed that drugs were detected in the vast majority of older drivers suspected for drunk or drugged driving. Ethanol was the most frequent drug detected, followed by zopiclone and diazepam. Older drivers combine drugs to a lesser degree than younger drivers, but their combination of ethanol and other drugs represents a considerable traffic risk. Lower concentrations of benzodiazepines are seen in older compared to younger drivers.

Is toxicity of PMMA (paramethoxymethamphetamine) associated with cytochrome P450 pharmacogenetics?

In 2010-2013, 29 fatal intoxications related to the designer drug paramethoxymethamphetamine (PMMA, 4-methoxymethamphetamine) occurred in Norway. The current knowledge about metabolism and toxicity of PMMA in humans is limited. Metabolism by the polymorphic cytochrome P450 (CYP) 2D6 enzyme to the psychoactive metabolite 4-hydroxymethamphetamine (OH-MA), and possibly by additional enzymes, is suggested to be involved in its toxicity. The aim of this work was to study the association between CYP genetics, PMMA metabolism and risk of fatal PMMA toxicity in humans. The frequency distribution of clinically relevant gene variants of CYP2D6, CYP2C9, CYP2C19 and CYP3A5, and the phenotypic blood CYP2D6 metabolic ratio (OH-MA/PMMA) in particular, were compared in fatal PMMA intoxications (n=17) and nonfatal PMMA abuse controls (n=30), using non-abusers (n=305) as references for the expected genotype frequencies in the Norwegian population. Our study demonstrated that the CYP2D6 enzyme and genotype are important in the metabolism of PMMA to OH-MA in humans, but that other enzymes are also involved in this biotransformation. In the fatal PMMA intoxications, the blood concentrations of PMMA were higher and the CYP2D6 metabolic ratios were lower, than in the nonfatal PMMA abuse controls (median (range) 2.1 (0.03-5.0) vs 0.3 (0.1-0.9) mg/L, and ratio 0.6 (0.0-4.6) vs 2.1 (0.2-7.4) p=0.021, respectively). Overall, our findings indicated that, in most cases, PMMA death occurred rapidly and at an early stage of PMMA metabolism, following the ingestion of large and toxic PMMA doses. We could not identify any genetic CYP2D6, CYP2C9, CYP2C19 or CYP3A5 predictive marker on fatal toxicity of PMMA in humans. The overrepresentation of the CYP2D6 poor metabolizer (PM) genotype found in the nonfatal PMMA abuse controls warrants further investigations.

Biomedical Applications of Biodegradable Polyesters

The focus in the field of biomedical engineering has shifted in recent years to biodegradable polymers and, in particular, polyesters. Dozens of polyester-based medical devices are commercially available, and every year more are introduced to the market. The mechanical performance and wide range of biodegradation properties of this class of polymers allow for high degrees of selectivity for targeted clinical applications. Recent research endeavors to expand the application of polymers have been driven by a need to target the general hydrophobic nature of polyesters and their limited cell motif sites. This review provides a comprehensive investigation into advanced strategies to modify polyesters and their clinical potential for future biomedical applications.

GHB pharmacology and toxicology: acute intoxication, concentrations in blood and urine in forensic cases and treatment of the withdrawal syndrome

The illicit recreational drug of abuse, γ-hydroxybutyrate (GHB) is a potent central nervous system depressant and is often encountered during forensic investigations of living and deceased persons. The sodium salt of GHB is registered as a therapeutic agent (Xyrem®), approved in some countries for the treatment of narcolepsy-associated cataplexy and (Alcover®) is an adjuvant medication for detoxification and withdrawal in alcoholics. Trace amounts of GHB are produced endogenously (0.5-1.0 mg/L) in various tissues, including the brain, where it functions as both a precursor and a metabolite of the major inhibitory neurotransmitter γ-aminobutyric acid (GABA). Available information indicates that GHB serves as a neurotransmitter or neuromodulator in the GABAergic system, especially via binding to the GABA-B receptor subtype. Although GHB is listed as a controlled substance in many countries abuse still continues, owing to the availability of precursor drugs, γ-butyrolactone (GBL) and 1,4-butanediol (BD), which are not regulated. After ingestion both GBL and BD are rapidly converted into GHB (t½ ~1 min). The Cmax occurs after 20-40 min and GHB is then eliminated from plasma with a half-life of 30-50 min. Only about 1-5% of the dose of GHB is recoverable in urine and the window of detection is relatively short (3-10 h). This calls for expeditious sampling when evidence of drug use and/or abuse is required in forensic casework. The recreational dose of GHB is not easy to estimate and a concentration in plasma of ~100 mg/L produces euphoria and disinhibition, whereas 500 mg/L might cause death from cardiorespiratory depression. Effective antidotes to reverse the sedative and intoxicating effects of GHB do not exist. The poisoned patients require supportive care, vital signs should be monitored and the airways kept clear in case of emesis. After prolonged regular use of GHB tolerance and dependence develop and abrupt cessation of drug use leads to unpleasant withdrawal symptoms. There is no evidence-based protocol available to deal with GHB withdrawal, apart from administering benzodiazepines.

Determination of safety margins for whole blood concentrations of alcohol and nineteen drugs in driving under the influence cases

Legislative limits for driving under the influence of 20 non-alcohol drugs were introduced in Norway in February 2012. Per se limits corresponding to blood alcohol concentrations (BAC) of 0.2g/kg were established for 20 psychoactive drugs, and limits for graded sanctions corresponding to BACs of 0.5 and 1.2g/kg were determined for 13 of these drugs. This new legislation made it possible for the courts to make sentences based on the analytical results, similar to the situation for alcohol. To ensure that the reported concentration is as least as high as the true concentration, with a 99% safety level, safety margins had to be calculated for each of the substances. Diazepam, tetrahydrocannabinol (THC) and alcohol were used as model substances to establish a new model for estimating the safety margins. The model was compared with a previous used model established several years ago, by a similar yet much simpler model, and they were found to be in agreement. The measurement uncertainties depend on the standard batch used, the work list and the measurements' replicate. A Bayesian modelling approach was used to determine the parameters in the model, using a dataset of 4700 diazepam positive specimens and 5400 THC positive specimens. Different safety margins were considered for low and high concentration levels of diazepam (≤2μM (0.6mg/L) and >2μM) and THC (≤0.01μM (0.003mg/L) and >0.01μM). The safety margins were for diazepam 19.5% (≤2μM) and 34% (>2μM), for THC 19.5% (≤0.01μM) and 24.9% (>0.01μM). Concentration dependent safety margins for BAC were based on a dataset of 29500 alcohol positive specimens, and were in the range 10.4% (0.1g/kg) to 4.0% (4.0g/kg) at a 99% safety level. A simplified approach was used to establish safety margins for the compounds amphetamine, MDMA, methamphetamine, alprazolam, phenazepam, flunitrazepam, clonazepam, nitrazepam, oxazepam, buprenorphine, GHB, methadone, ketamine, cocaine, morphine, zolpidem and zopiclone. The safety margins for these drugs were in the range 34-41%.

Repetitive genomic insertion of gene-sized dsDNAs by targeting the promoter region of a counter-selectable marker

Genome engineering can be used to produce bacterial strains with a wide range of desired phenotypes. However, the incorporation of gene-sized DNA fragments is often challenging due to the intricacy of the procedure, off-target effects, and low insertion efficiency. Here we report a genome engineering method enabling the continuous incorporation of gene-sized double-stranded DNAs (dsDNAs) into the Escherichia coli genome. DNA substrates are inserted without introducing additional marker genes, by synchronously turning an endogenous counter-selectable marker gene ON and OFF. To accomplish this, we utilized λ Red protein-mediated recombination to insert dsDNAs within the promoter region of a counter-selectable marker gene, tolC. By repeatedly switching the marker gene ON and OFF, a number of desired gene-sized dsDNAs can be inserted consecutively. With this method, we successfully inserted approximately 13 kb gene clusters to generate engineered E. coli strains producing 1,4-butanediol (1,4-BDO).

A fatal intoxication with phenazone (antipyrine)

Phenazone is a non-opioid analgesic used to treat acute mild to moderate pain, and is considered to be a safe drug. It is most often sold as a nonprescription/over-the-counter drug. Very few fatalities due to phenazone overdoses are reported in the literature. We present a case where a man in his early sixties was found dead in his home in the bottom of a staircase, the scene suggesting that death might have been caused by blunt force injury. However, in spite of the apparently dramatic scene, the gross findings at autopsy did not reveal lethal injuries. Whole blood from the femoral vein was collected during autopsy and screened for drugs of abuse and medicinal drugs. The only toxicological findings were a very high concentration of phenazone (280mg/L) and a high therapeutic concentration of caffeine (34mg/L). An UPLC-MS/MS method was used for quantification of the drugs.

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.

Impairment due to amphetamines and benzodiazepines, alone and in combination

INTRODUCTION

The impairing effects of combined use of amphetamines and benzodiazepines among recreational drug users are not well described, but knowledge about this is important in the risk assessment of such combined drug use. The aim of this study was to compare the impairment, among apprehended drivers, as judged by a clinical test of impairment (CTI), in cases where a combination of amphetamines and benzodiazepines was detected, in blood, with cases where only one of the two drug groups was detected.

METHODS

The results of CTI judgments were compared to toxicological drug tests of blood samples that were obtained at the time of CTI screening in cases containing amphetamines only, cases containing different benzodiazepines only, and cases containing a combination of amphetamines and benzodiazepines.

RESULTS

There were significantly more drivers being judged as impaired in the combined group (n = 777), compared both with amphetamines alone (n = 267, χ(2) = 47.8, p < 0.001) and benzodiazepines alone (n = 153, χ(2) = 7.0, p = 0.008). This was also seen when only including the lowest concentrations of benzodiazepines (χ(2) = 4.3, p = 0.038). The concentrations of the drugs were higher in the single drug groups, compared with the combined group.

CONCLUSION

This study indicates that during real-life driving, those influenced by both amphetamines and benzodiazepines are more impaired, as judged by the CTI, compared with those influenced by either drug alone, although the combined group showed lower drug concentrations.

Physical exercise and epigenetic modulation: elucidating intricate mechanisms

Physical exercise induces several metabolic adaptations to meet increased energy requirements. Promoter DNA methylation, histone post-translational modifications, or microRNA expression are involved in the gene expression changes implicated in metabolic adaptation after exercise. Epigenetic modifications and many epigenetic enzymes are potentially dependent on changes in the levels of metabolites, such as oxygen, tricarboxylic acid cycle intermediates, 2-oxoglutarate, 2-hydroxyglutarate, and β-hydroxybutyrate, and are therefore susceptible to the changes induced by exercise in a tissue-dependent manner. Most of these changes are regulated by important epigenetic modifiers that control DNA methylation (DNA methyl transferases, and ten-eleven-translocation proteins) and post-translational modifications in histone tails controlled by histone acetyltransferases, histone deacetylases, and histone demethylases (jumonji C proteins, lysine-specific histone demethylase, etc.), among others. Developments in mass spectrometry approaches and the comprehension of the interconnections between epigenetics and metabolism further increase our understanding of underlying epigenetic mechanisms, not only of exercise, but also of disease and aging. In this article, we describe several of these substrates and signaling molecules regulated by exercise that affect some of the most important epigenetic mechanisms, which, in turn, control the gene expression involved in metabolism.