Therapeutic drug monitoring of carbamazepine and its metabolite in children from dried blood spots using liquid chromatography and tandem mass spectrometry

Monitoring levetiracetam concentration in saliva during pregnancy is stable and feasible

AIMS

This multicenter prospective cohort study (registration no. ChiCTR2000032089) aimed to investigate the relationship between saliva and plasma levetiracetam concentrations to determine whether saliva could be used for routine monitoring of levetiracetam during pregnancy.

METHODS

The slot concentrations of levetiracetam in simultaneously obtained saliva and plasma samples were measured using UPLC-MS/MS. The correlations between saliva and plasma levetiracetam concentrations and the dose-normalized concentrations were compared among pregnant women in different stages and nonpregnant control participants with epilepsy.

RESULTS

In total, 231 patients with 407 plasma and saliva sample pairs were enrolled from 39 centers. Linear relationships between salivary and plasma levetiracetam concentrations were reported in the enrolled population (r = 0.898, p < 0.001), including pregnant (r = 0.935, p < 0.001) and nonpregnant participants (r = 0.882, p < 0.001). Plasma concentrations were moderately higher than saliva concentrations, with ratios of saliva to plasma concentrations of 0.98 for nonpregnant women, 0.98, 1, and 1.12 for pregnant women during the first trimester, the second trimester, the and third trimester, respectively. The effective range of saliva levetiracetam concentration was found to be 9.98 μg/mL (lower limit) with an area under the curve (AUC) of 0.937 (95% confidence intervals, 0.915-0.959), sensitivity of 88.9%, specificity of 86.8%, and p < 0.001, to 24.05 μg/mL (upper limit) with an AUC of 0.952 (0.914-0.99), sensitivity of 100%, specificity of 92.3%, and p = 0.007.

CONCLUSION

The saliva/plasma concentration ratio of levetiracetam remains constant during pregnancy and is similar to that in non-pregnant individuals. Monitoring levetiracetam concentration in saliva during pregnancy should be widely promoted.

Dried Blood Spots-A Platform for Therapeutic Drug Monitoring (TDM) and Drug/Disease Response Monitoring (DRM)

This review provides an overview on the current applications of dried blood spots (DBS) as matrices for therapeutic drug (TDM) and drug or disease response monitoring (DRM). Compared with conventional methods using plasma/serum, DBS offers several advantages, including minimally invasiveness, a small blood volume requirement, reduced biohazardous risk, and improved sample stability. Numerous assays utilising DBS for TDM have been reported in the literature over the past decade, covering a wide range of therapeutic drugs. Several factors can affect the accuracy and reliability of the DBS sampling method, including haematocrit (HCT), blood volume, sampling paper and chromatographic effects. It is crucial to evaluate the correlation between DBS concentrations and conventional plasma/serum concentrations, as the latter has traditionally been used for clinical decision. The feasibility of using DBS sampling method as an option for home-based TDM is also discussed. Furthermore, DBS has also been used as a matrix for monitoring the drug or disease responses (DRM) through various approaches such as genotyping, viral load measurement, assessment of inflammatory factors, and more recently, metabolic profiling. Although this research is still in the development stage, advancements in technology are expected to lead to the identification of surrogate biomarkers for drug treatment in DBS and a better understanding of the correlation between DBS drug levels and drug responses. This will make DBS a valuable matrix for TDM and DRM, facilitating the achievement of pharmacokinetic and pharmacodynamic correlations and enabling personalised therapy.

Differentiation of isomeric metabolites of carbamazepine based on acid-base properties; Experimental vs theoretical approach

Metabolism of carbamazepine is complex and leads to the three isomeric derivatives whose occurrence is dependent on the type of sample material. Their unambiguous differentiation is overall important. In this work, the qualitative analysis of 2-hydroxycarbamazepine, 3-hydroxycrbamazepine and carbamazepine-10,11-epoxide was attempted for the first time using capillary zone electrophoresis, based on the models linking electrophoretic mobility with pK_a value determining the acidity of the hydroxyl groups. For this purpose, pK_a values ​​were determined using electrophoretic and theoretical methods, and then the compliance of the obtained mobility models with the measured values ​​was analyzed. Despite the slight difference in acidity ​​(0.3-0.4 pH unit), the obtained results prove that the correct identification of the metabolites under consideration, and reliable prediction of the selectivity of their separation, are possible on the basis of experimentally determined pK_a values, even with highly simplified methods assuming the lack of certain data. However, it is important to choose the optimal pH value, which should be close to pK_a. On the other hand, worse results were obtained for the theoretically determined mobilities, which differed significantly from the experimental values. An attempt was also made to explain the acidity of hydroxycarbamazepines and the associated thermodynamic parameters - deprotonation enthalpy and entropy, with respect to their structure. The lack of intramolecular hydrogen bonds and the significant contribution of entropic effects stabilizing the protonated form seems to be significant. The higher pK_a value for CBZ-2-OH probably results from the stronger effect of the energetically unfavorable organization of solvent dipoles due to ionization.

A new molecular imprinted PEDOT glassy carbon electrode for carbamazepine detection

An electrochemical sensor for the detection of carbamazepine was fabricated by the electropolymerization of PEDOT on glassy carbon electrodes. Molecular imprinted polymer sites were synthesized by cyclic voltammetry on the electrodes' surfaces providing high selectivity and sensitivity towards carbamazepine molecules. Scanning electron microscopy validated the formation of the polymer. Extraction of carbamazepine from the polymer was performed by immersion in acetonitrile and validated by ultraviolet-visible spectroscopy along with cyclic voltammetry experiments comparing pre- and post-template extraction data. Further cyclic voltammetry and square-wave voltammetry tests aided in characterizing the electrodes' response to carbamazepine concentration in PBS solution with [Fe(CN)₆]^3-/4- as a redox pair/mediator. The limits of detection and quantification were found to be 0.98 x 10^-3 M and 2.97 x 10^-3 M respectively. The biosensor was highly sensitive to carbamazepine molecules in comparison to non-imprinted electrodes, simple to construct and easy to operate.

A review of recent advances in microsampling techniques of biological fluids for therapeutic drug monitoring

Conventional sampling of biological fluids often involves a bulk quantity of samples that are tedious to collect, deliver and process. Miniaturized sampling approaches have emerged as promising tools for sample collection due to numerous advantages such as minute sample size, patient friendliness and ease of shipment. This article reviews the applications and advances of microsampling techniques in therapeutic drug monitoring (TDM), covering the period January 2015 - August 2020. As whole blood is the gold standard sampling matrix for TDM, this article comprehensively highlights the most historical microsampling technique, the dried blood spot (DBS), and its development. Advanced developments of DBS, ranging from various automation DBS, paper spray mass spectrometry (PS-MS), 3D dried blood spheroids and volumetric absorptive paper disc (VAPD) and mini-disc (VAPDmini) are discussed. The volumetric absorptive microsampling (VAMS) approach, which overcomes the hematocrit effect associated with the DBS sample, has been employed in recent TDM. The sample collection and sample preparation details in DBS and VAMS are outlined and summarized. This review also delineates the involvement of other biological fluids (plasma, urine, breast milk and saliva) and their miniaturized dried matrix forms in TDM. Specific features and challenges of each microsampling technique are identified and comparison studies are reviewed.

Development of a new method for drug detection based on a combination of the dried blood spot method and capillary electrophoresis

The aim of this study was to develop a new approach to sample preparation of biological material based on a combination of the Dried Blood Spot (DBS) method and capillary electrophoresis coupled with mass spectrometry (CE-MS) for the analysis of blood samples collected in vivo or post-mortem. The proposed approach allowed the identification of typical drugs from different groups, such as tricyclic antidepressants (amitriptyline, imipramine), selective serotonin reuptake inhibitors (citalopram), benzodiazepines (tetrazepam) and hypnotics (zolpidem). In this study, a blood sample was spotted on FTA DMPK C cards, then dried, and 6-mm discs were cut out. The sample preparation procedure involved microwave-assisted extraction (MAE). Various extraction agents, temperatures and durations of extraction were examined in order to achieve the highest efficiency of the process. The method was subjected to a validation procedure. Limits of detection (LOD = 1.76 - 14.7 ng/mL) and quantification (LOQ = 5.25 - 49.0 ng/mL), inter- (CV = 1.31 - 9.43%) and intra- (CV = 3.26 - 18.52%) day precision of the determinations, recovery (RE = 85.0-105.4%) and matrix effect on ionization of analytes (ME = 98.6-105.5%) were determined. Furthermore, the developed DBS/MAE/CM-MS method was selective and analytes present in the blood applied on DBS cards were found to be stable after 7 and after 14 days. Moreover, the developed method was successfully applied to the analysis of both post-mortem samples and blood samples taken from patients treated with the analyzed drugs.

Simultaneous Determination of Phenobarbital, Phenytoin, Carbamazepine and Carbamazepine-10,11-epoxide in Plasma of Epileptic Patients

Background: Quantitative analyses of antiepileptic drugs are required in clinic and to rational dosage adjustment, the clinician needs the blood levels of these drugs. A high-performance liquid chromatography with spectrophotometric detection has been developed and validated for simultaneous determination of some antiepileptic drugs in plasma of patients with epilepsy. Methods: A simple procedure based on deproteinization by acetonitrile was used for pre-treatment of plasma samples. Liquid chromatographic analysis was carried out on a Nova-Pak® C18 analytical column, using a ternary mixture of potassium dihydrogen phosphate buffer (pH 6.0)-acetonitrile-2-propanol (63:22:15, v/v/v) as the mobile phase, at a flow rate of 1.0 mL min-1. Results: Calibration curves were linear over a range of 1–40 µg mL-1 for phenobarbital, 1–30 µg mL-1 for phenytoin, 0.3–15 µg mL-1 for carbamazepine and 0.5–6 µg mL-1 for carbamazepine epoxide. Conclusion: The simple sample pre-treatment, combined with the fast chromatographic run was used for the determination of antiepileptic drugs for a large number of patient samples.

Metabolomics technology and bioinformatics for precision medicine

Precision medicine is rapidly emerging as a strategy to tailor medical treatment to a small group or even individual patients based on their genetics, environment and lifestyle. Precision medicine relies heavily on developments in systems biology and omics disciplines, including metabolomics. Combination of metabolomics with sophisticated bioinformatics analysis and mathematical modeling has an extreme power to provide a metabolic snapshot of the patient over the course of disease and treatment or classifying patients into subpopulations and subgroups requiring individual medical treatment. Although a powerful approach, metabolomics have certain limitations in technology and bioinformatics. We will review various aspects of metabolomics technology and bioinformatics, from data generation, bioinformatics analysis, data fusion and mathematical modeling to data management, in the context of precision medicine.

Presoaking dried blood spot with water improves efficiency for small-molecule analysis

The current method of extracting small molecules from dried blood spots (DBSs) and liquid blood is similar. However, owing to their different physical characteristics, a modification of the extraction process for DBS is required. We propose a modified method involving presoaking in water that results in better extraction efficiency for small-molecule analysis than the conventional protein precipitation method. Using blood and DBSs from eight subjects, the similarities, recovery rates and extraction efficiencies of both methods were compared. Quantitative analysis showed that seven and six out of ten conditions for the modified method group exhibited almost 100% recovery and extraction efficiency rates, respectively, compared with the conventional method group. Taken together, the results suggest that a presoaking step is needed for efficient DBS analysis.

Preparation and evaluation of a porous molecularly imprinted polymer for selective recognition of the antiepileptic drug carbamazepine

A novel and porous molecularly imprinted polymer (PMIP) was synthesized and used as a solid-phase extraction adsorbent for preconcentration of carbamazepine (CBZ) prior to its quantitation by high-performance liquid chromatography (HPLC) in various sample forms (e.g., drinking water, river water, hospital wastewater, and pharmaceuticals). PMIP-CBZ was applied to a polymerization process in which polystyrene spheres were coated with a silica layer. Removal of polystyrene spheres and formation of porous silica facilitated the recovery of CBZ (99.4%) during the extraction process. Site accessibility to the surface of PMIP-CBZ increased the density of high-recognition sites. PMIP-CBZ was characterized by Fourier-transform infrared spectroscopy and scanning electron microscopy. The key variables influencing the extraction efficiency of PMIP (e.g., adsorbent loading, eluent type, eluent volume, reusability of the adsorbent, and cross-reactivity) were optimized. The optimized protocol was successfully employed to quantify CBZ with limit of detection and limit of quantification as 0.082 and 0.270 ng/mL, respectively (linear detection range: 0.5-250 ng/mL and a relative standard deviation:  < 5%). Use of the PMIP adsorbent resulted in a sensitive and stable method for efficiently quantitation of CBZ from various real sample matrices.

Dried blood spots sampling in case samples deprived of hematocrit level information - Investigation and calculation strategy

The application of a new calculation strategy for the psychotropic drug concentration in blood and bone marrow samples in the form of dried blood spots (DBS) was the main aim of the study. The standard DBS method consists of the deposition of the capillary blood onto the dedicated paper cards. Nowadays, the DBS technique is seen as a fast and partly superior microsampling alternative methodology replacing the conventional venous blood and plasma collection. The calculation approach to drug concentration in the limited volume of the case sample, where the hematocrit level cannot be determined, constitutes an important step of this method. The method has been validated and the results of the determination of alprazolam and diazepam previously spiked in the post-mortem blood and bone marrow sample have been satisfactory.

Effects of Carbamazepine and Valproate on Serum Aspartate Aminotransferase, Alanine Aminotransferase and Gamma - Glutamyltransferase in Children

Introduction:

Epilepsy is one of the most common neurological diseases in childhood and adolescence. Carbamazepine (CBZ) and valproate (VPA) have been widely used as the first generation of antiepileptic drugs (AED).

Aim:

The aim of the study has been to evaluate and compare the effect of CBZ and VPA monotherapy on aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyltransferase (GGT) serum levels in children.

Material and methods:

The study has included 100 patients (boys 57/girls 43, age range 1 to 18 years), who have been treated with CBZ or VPA, as initial monotherapy, for at least 12 months. Patients with liver lesions or patients who have been treated with other drugs have been excluded from the study. The initial serum enzyme levels (AST, ALT and GGT) and after 12 months of treatment have been compared.

Results:

53/100 (53%) patients have been treated with CBZ and 47/100 (47%) patients have been treated with VPA.The initial level of enzymes were within the referece range. After one year-long treatment AST was elevated at 4/53 (7.5%) CBZ patients and 9/47 (19.15%) VPA patients (x2 test =3.965, p<0.05). ALT was elevated at 5/53 (9.4%) CBZ patients and 9/47 (19.15%) VPA patients (x2 test =6.953, p<0.05). GGT was elevated at 18/53 (34%) CBZ patients and 7/47 (14.9%) VPA patients (x2 test =4.831, p<0.05).

Conclusion:

The levels of enzymes AST and ALT have been elevated statistically significant in VPA group and GGT in CBZ group.

Simultaneous Determination of Carbamazepine and Carbamazepine-10,11-epoxide in Different Biological Matrices by LC-MS/MS

An uncomplicated, sensitive liquid chromatography linked to mass spectrometry (LC/MS) for evaluation of carbamazepine and carbamazepine-10,11-epoxide (its metabolite) in human plasma, human saliva, rat plasma, and rabbit plasma was developed. Analyses were conducted on a Zorbax SB-C18, 100 mm × 3 mm ID, 3.5 μm column, at a column temperature of 40 ºC. The mobile phase was comprised of 0.1% formic acid in water and methanol in a 35 : 65 (v/v) ratio, with a flow rate of 0.4 mL/min. Lacosamide was utilized as internal standard. Under these chromatographic conditions, the retention times of lacosamide, carbamazepine-10,11-epoxide, and carbamazepine were 1.4 min, 1.6 min, and 2.2 min, respectively. The quantification of the analytes was performed using multiple reaction monitoring, with the use of a triple quadrupole mass spectrometer with electrospray positive ionization. The monitored ions were m/z 194 derived from m/z 237 for carbamazepine, m/z 180 derived from m/z 253 for carbamazepine-10,11-epoxide, and m/z 108 derived from m/z 251 for lacosamide. The samples were prepared by protein precipitation from 0.2 mL of plasma/saliva using 0.6 mL of internal standard solution in methanol. Calibration curves were constructed over the ranges 1.1–17.6 µg/mL and 0.23–5.47 µg/mL for carbamazepine and carbamazepine-epoxide, respectively. The coefficients of determination obtained by using a weighted (1/x) linear regression were greater than 0.994. The reported LC-MS/MS method was applied to preclinical pharmacokinetic studies and therapeutic drug monitoring.

Determination of serum carbamazepine concentration using dried blood spot specimens for resource-limited settings

OBJECTIVES

Carbamazepine (CBZ) is a commonly used anti-epileptic in rural hospitals in India. These hospitals lack the facilities to measure CBZ concentration; however, in larger hospitals this is performed using high performance liquid chromatography (HPLC). Dried blood spot (DBS) represents a feasible matrix for safe transportation by post/courier. This study was to determine whether the concentration of CBZ in serum can be predicted from that measured in DBS using an inexpensive HPLC method and inexpensive standard filter paper.

METHODS

CBZ in serum and DBS from 80 epileptic patients were measured using a validated HPLC assay. The data was then randomly divided into two groups; simple Deming regression was performed with the first group and validation was performed using the second.

RESULTS

There was a good correlation between the serum and DBS concentrations (r = 0.932) in the first group. The regression equation obtained was: predicted serum concentration = DBS concentration x 0.83 + 1.09. In the validation group, the correlation between the predicted and actual serum concentrations was also good (r = 0.958), and the mean difference between them was only 0.28 μg/ml (p = 0.8062). The imprecision and bias in both the groups were acceptable.

CONCLUSION

Using inexpensive materials, serum CBZ concentrations can be accurately predicted from DBS specimens. This method can be recommended for the therapeutic drug monitoring of CBZ in resource-limited settings.

Dried Blood Spot sampling in psychiatry: Perspectives for improving therapeutic drug monitoring

Assessment of drug concentrations is indicated to guide dosing of a selected number of drugs used in psychiatry. Conventionally this is done by vena puncture. Novel sampling strategies such as dried blood spot (DBS) sampling have been developed for various drugs, including antipsychotics, antidepressants and mood-stabilizers. DBS sampling is typically performed by means of a finger prick. This method allows for remote sampling, which means that patients are not required to travel to a health care facility. The number of DBS assays for drugs used in psychiatry has increased over the last decade and includes antidepressants (tricyclic and serotonin and/or norepinephrine reuptake inhibitors), mood stabilizers and first- and second-generation antipsychotics. Available assays often comply with analytical validation criteria but are seldom used in routine clinical care. Little attention has been paid to the clinical validation and implementation processes of home sampling. Ideally, not only medicines but also clinical chemistry parameters should be measured within the same sample. This article reflects on the position of DBS remote sampling in psychiatry and provides insight in the requisites of making such a sampling tool successful.

The significance of a new parameter – plasma protein binding – in therapeutic drug monitoring and its application to carbamazepine in epileptic patients

The primary cause of the variability of C_f in pharmacology is the change in plasma protein binding (PPB), thus PPB monitoring should be applied to a better individualization of drug dosage regimens in clinical patients.

The Influence of Solid Microneedles on the Transdermal Delivery of Selected Antiepileptic Drugs

The aim of this project was to examine the effect of microneedle rollers on the percutaneous penetration of tiagabine hydrochloride and carbamazepine across porcine skin in vitro. Liquid chromatography-mass spectrometric analysis was carried out using an Agilent 1200 Series HPLC system coupled to an Agilent G1969A TOF-MS system. Transdermal flux values of the drugs were determined from the steady-state portion of the cumulative amount versus time curves. Following twelve hours of microneedle roller application, there was a 6.74-fold increase in the percutaneous penetration of tiagabine hydrochloride (86.42 ± 25.66 µg/cm²/h) compared to passive delivery (12.83 ± 6.30 µg/cm²/h). For carbamazepine in 20% ethanol, passive transdermal flux of 7.85 ± 0.60 µg/cm²/h was observed compared to 10.85 ± 0.11 µg/cm²/h after microneedle treatment. Carbamazepine reconstituted in 30% ethanol resulted in only a 1.19-fold increase in drug permeation across porcine skin (36.73 ± 1.83 µg/cm²/h versus 30.74 ± 1.32 µg/cm²/h). Differences in flux values of untreated and microneedle-treated porcine skin using solid microneedles for the transdermal delivery of tiagabine were statistically significant. Although there were 1.38- and 1.19-fold increases in transdermal flux values of carbamazepine when applied as 20% and 30% ethanol solutions across microneedle-treated porcine skin, respectively, the increases were not statistically significant.

Quantitative mass spectrometry methods for pharmaceutical analysis

Quantitative pharmaceutical analysis is nowadays frequently executed using mass spectrometry. Electrospray ionization coupled to a (hybrid) triple quadrupole mass spectrometer is generally used in combination with solid-phase extraction and liquid chromatography. Furthermore, isotopically labelled standards are often used to correct for ion suppression. The challenges in producing sensitive but reliable quantitative data depend on the instrumentation, sample preparation and hyphenated techniques. In this contribution, different approaches to enhance the ionization efficiencies using modified source geometries and improved ion guidance are provided. Furthermore, possibilities to minimize, assess and correct for matrix interferences caused by co-eluting substances are described. With the focus on pharmaceuticals in the environment and bioanalysis, different separation techniques, trends in liquid chromatography and sample preparation methods to minimize matrix effects and increase sensitivity are discussed. Although highly sensitive methods are generally aimed for to provide automated multi-residue analysis, (less sensitive) miniaturized set-ups have a great potential due to their ability for in-field usage.This article is part of the themed issue 'Quantitative mass spectrometry'.

Dried blood spots analysis with mass spectrometry: Potentials and pitfalls in therapeutic drug monitoring

Therapeutic drug monitoring (TDM) relays in the availability of specialized laboratory assays, usually available in reference centers that are not accessible to all patients. In this context, there is a growing interest in the use of dried blood spot (DBS) sampling, usually obtained from finger pricks, which allows simple and cost-effective logistics in many settings, particularly in Developing Countries. The use of DBS assays to estimate plasma concentrations is highly dependent on the hematocrit of the blood, as well as the particular characteristics of the measured analyte. DBS assays require specific validation assays, most of them are related to hematocrit effects. In the present manuscript, the application of mass spectrometric assays for determination of drugs for TDM purposes in the last ten years is reviewed, as well as the particular validation assays for new DBS methods.