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Fairman K, Choi MK, Gonnabathula P, Lumen A, Worth A, Paini A, Li M. An Overview of Physiologically-Based Pharmacokinetic Models for Forensic Science. TOXICS 2023; 11:126. [PMID: 36851001 PMCID: PMC9964742 DOI: 10.3390/toxics11020126] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/16/2022] [Accepted: 01/25/2023] [Indexed: 06/18/2023]
Abstract
A physiologically-based pharmacokinetic (PBPK) model represents the structural components of the body with physiologically relevant compartments connected via blood flow rates described by mathematical equations to determine drug disposition. PBPK models are used in the pharmaceutical sector for drug development, precision medicine, and the chemical industry to predict safe levels of exposure during the registration of chemical substances. However, one area of application where PBPK models have been scarcely used is forensic science. In this review, we give an overview of PBPK models successfully developed for several illicit drugs and environmental chemicals that could be applied for forensic interpretation, highlighting the gaps, uncertainties, and limitations.
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Affiliation(s)
- Kiara Fairman
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
| | - Me-Kyoung Choi
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
| | - Pavani Gonnabathula
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
| | - Annie Lumen
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
| | - Andrew Worth
- European Commission, Joint Research Centre (JRC), 21027 Ispra, Italy
| | | | - Miao Li
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
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Faisal M, Karia S, Shah N, Andrade C. Survival of Combined Overdose with Very High Doses of Clozapine and Blonanserin: A Case Report. Indian J Psychol Med 2023; 45:99-100. [PMID: 36778615 PMCID: PMC9896118 DOI: 10.1177/02537176221139106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mohammad Faisal
- Dept. of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Sagar Karia
- Dept. of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Nilesh Shah
- Dept. of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Chittaranjan Andrade
- Dept. of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences, Bangaluru, Karnataka, India
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St Francis H, Renny MH, Biary R, Howland MA, Su MK. Clozapine Toxicity in Two Young Siblings Due to a Pharmacy Dispensing Error: a Pediatric Case Report. J Med Toxicol 2022; 18:340-343. [PMID: 36018467 PMCID: PMC9492813 DOI: 10.1007/s13181-022-00909-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 10/15/2022] Open
Abstract
INTRODUCTION Clozapine is an atypical antipsychotic used to treat refractory schizophrenia; in both therapeutic use and overdose, it can cause significant toxicity. We report two young siblings who developed altered mental status after ingesting clozapine due to a pharmacy dispensing error. CASE REPORT A 5-year-old girl and her 19-month-old sister presented to the emergency department (ED) with altered mental status after they took their first dose of what was believed to be cimetidine, prescribed to treat molluscum contagiosum. Both children were discharged after a brief period of observation in the ED. Two days later, when the older child continued to be symptomatic, their mother used a web-based pill identifier and discovered that the pills dispensed by the pharmacy were 200 mg clozapine tablets, not the cimetidine that had been prescribed. Ingestion was confirmed with an elevated serum clozapine concentration in the older child of 17 mcg/L at 85 hours post-ingestion (adult therapeutic range: 350-600 mcg/L). Both children had complete resolution of their symptoms 4 days following the ingestion with supportive care alone. DISCUSSION We report two cases of pediatric clozapine toxicity due to a pharmacy dispensing error. The error was due, in part, to similarly named medications being stored adjacent to each other on a shelf. Dispensing errors are not rare occurrences and their root causes are multi-factorial. This case demonstrates the importance of reducing such errors, particularly for medications with potential for severe toxicity.
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Affiliation(s)
- Hannah St Francis
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA.
| | - Madeline H Renny
- Emergency Medicine, Pediatrics, and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Rana Biary
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Mary Ann Howland
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
- St. John's University College of Pharmacy and Health Sciences, New York, NY, USA
- Bellevue Hospital Emergency Department, New York, NY, USA
| | - Mark K Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
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Bagade R, Karia S, Shah N, Andrade C. Surviving a 10,000 mg overdose of clozapine: A case report. Schizophr Res 2022; 239:31. [PMID: 34814100 DOI: 10.1016/j.schres.2021.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/04/2021] [Accepted: 11/07/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Rahul Bagade
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai 400022, India
| | - Sagar Karia
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai 400022, India.
| | - Nilesh Shah
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai 400022, India
| | - Chittaranjan Andrade
- Department of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences, Bangalore 560 029, India
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5
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Ketola RA, Kriikku P. Drug concentrations in post‐mortem specimens. Drug Test Anal 2019; 11:1338-1357. [DOI: 10.1002/dta.2662] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Raimo A. Ketola
- Forensic Toxicology UnitNational Institute for Health and Welfare (THL) Mannerheimintie 166 FI‐00270 Helsinki Finland
| | - Pirkko Kriikku
- Forensic Toxicology UnitNational Institute for Health and Welfare (THL) Mannerheimintie 166 FI‐00270 Helsinki Finland
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Fatal Case of Acute Cardiac Failure After Long-Term Physical Restraint of Patient Treated With Clozapine in Psychiatric Ward. J Clin Psychopharmacol 2018; 38:270-272. [PMID: 29601317 DOI: 10.1097/jcp.0000000000000870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bévalot F, Cartiser N, Bottinelli C, Fanton L, Guitton J. État de l’art de l’analyse de la bile en toxicologie médicolégale. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2017. [DOI: 10.1016/j.toxac.2016.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Söderberg C, Wernvik E, Tillmar A, Spigset O, Kronstrand R, Reis M, Jönsson AK, Druid H. Antipsychotics Postmortem fatal and non-fatal reference concentrations. Forensic Sci Int 2016; 266:91-101. [DOI: 10.1016/j.forsciint.2016.05.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/14/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
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Bévalot F, Cartiser N, Bottinelli C, Guitton J, Fanton L. State of the art in bile analysis in forensic toxicology. Forensic Sci Int 2016; 259:133-54. [DOI: 10.1016/j.forsciint.2015.10.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 10/17/2015] [Accepted: 10/26/2015] [Indexed: 02/07/2023]
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Bévalot F, Cartiser N, Bottinelli C, Fanton L, Guitton J. Vitreous humor analysis for the detection of xenobiotics in forensic toxicology: a review. Forensic Toxicol 2015; 34:12-40. [PMID: 26793276 PMCID: PMC4705140 DOI: 10.1007/s11419-015-0294-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/21/2015] [Indexed: 01/10/2023]
Abstract
Vitreous humor (VH) is a gelatinous substance contained in the posterior chamber of the eye, playing a mechanical role in the eyeball. It has been the subject of numerous studies in various forensic applications, primarily for the assessment of postmortem interval and for postmortem chemical analysis. Since most of the xenobiotics present in the bloodstream are detected in VH after crossing the selective blood-retinal barrier, VH is an alternative matrix useful for forensic toxicology. VH analysis offers particular advantages over other biological matrices: it is less prone to postmortem redistribution, is easy to collect, has relatively few interfering compounds for the analytical process, and shows sample stability over time after death. The present study is an overview of VH physiology, drug transport and elimination. Collection, storage, analytical techniques and interpretation of results from qualitative and quantitative points of view are dealt with. The distribution of xenobiotics in VH samples is thus discussed and illustrated by a table reporting the concentrations of 106 drugs from more than 300 case reports. For this purpose, a survey was conducted of publications found in the MEDLINE database from 1969 through April 30, 2015.
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Affiliation(s)
- Fabien Bévalot
- Laboratoire LAT LUMTOX, 71 Avenue Rockefeller, 69003 Lyon, France.,Institut de Médecine Légale, Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, 8 Avenue Rockefeller, 69373 Lyon Cedex 08, France
| | - Nathalie Cartiser
- Laboratoire de Toxicologie, ISPB-Faculté de Pharmacie, Université de Lyon, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69373 Lyon Cedex 08, France
| | | | - Laurent Fanton
- Département de Médecine Légale, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Place D'Arsonval, 69437 Lyon Cedex 03, France.,CREATIS CNRS UMR 5220, INSERM U1044, Université de Lyon, Université Claude Bernard Lyon 1, INSA Lyon, 7 Avenue Jean Capelle, 69621 Villeurbanne Cedex, France
| | - Jérôme Guitton
- Laboratoire de Toxicologie, ISPB-Faculté de Pharmacie, Université de Lyon, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69373 Lyon Cedex 08, France.,Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, 165 Chemin Grand Revoyet, 69495 Pierre Bénite Cedex, France
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Tylutki Z, Polak S. Plasma vs heart tissue concentration in humans - literature data analysis of drugs distribution. Biopharm Drug Dispos 2015; 36:337-351. [PMID: 25765563 DOI: 10.1002/bdd.1944] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 01/05/2015] [Accepted: 03/04/2015] [Indexed: 12/12/2022]
Abstract
Little is known about the uptake of drugs into the human heart, although it is of great importance nowadays, when science desires to predict tissue level behavior rather than to measure it. Although the drug concentration in cardiac tissue seems a better predictor for physiological and electrophysiological changes than its level in plasma, knowledge of this value is very limited. Tissue to plasma partition coefficients (Kp) come to rescue since they characterize the distribution of a drug among tissues as being one of the input parameters in physiologically based pharmacokinetic (PBPK) models. The article reviews cardiac surgery and forensic medical studies to provide a reference for drug concentrations in human cardiac tissue. Firstly, the focus is on whether a drug penetrates into heart tissue at a therapeutic level; the provided values refer to antibiotics, antifungals and anticancer drugs. Drugs that directly affect cardiomyocyte electrophysiology are another group of interest. Measured levels of amiodarone, digoxin, perhexiline and verapamil in different sites in human cardiac tissue where the compounds might meet ion channels, gives an insight into how these more lipophilic drugs penetrate the heart. Much data are derived from postmortem studies and they provide insight to the cardiac distribution of more than 200 drugs. The analysis depicts potential problems in defining the active concentration location, what may indirectly suggest multiple mechanisms involved in the drug distribution within the heart. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Zofia Tylutki
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Str, , 30-688, Cracow, Poland
| | - Sebastian Polak
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Str, , 30-688, Cracow, Poland
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Wohlfarth A, Toepfner N, Hermanns-Clausen M, Auwärter V. Sensitive quantification of clozapine and its main metabolites norclozapine and clozapine-N-oxide in serum and urine using LC-MS/MS after simple liquid–liquid extraction work-up. Anal Bioanal Chem 2011; 400:737-46. [DOI: 10.1007/s00216-011-4831-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 02/19/2011] [Accepted: 02/21/2011] [Indexed: 10/18/2022]
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13
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Cobaugh DJ, Erdman AR, Booze LL, Scharman EJ, Christianson G, Manoguerra AS, Martin Caravati E, Chyka PA, Woolf AD, Nelson LS, Troutman WG. Atypical antipsychotic medication poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2008; 45:918-42. [DOI: 10.1080/15563650701665142] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kłys M, Rojek S, Rzepecka-Woźniak E. Neonatal death following clozapine self-poisoning in late pregnancy: an unusual case report. Forensic Sci Int 2007; 171:e5-e10. [PMID: 17544236 DOI: 10.1016/j.forsciint.2007.04.216] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 04/13/2007] [Accepted: 04/19/2007] [Indexed: 10/23/2022]
Abstract
The report presents a fatal poisoning of a neonate occurring in the final stage of gestational life and evoked by his mother, who, while 9 months pregnant, took a toxic dose of clozapine aiming at committing suicide. She was also severely poisoned, but ultimately was saved. The woman had been taking the medication due to schizophrenia and depression prior to conception, and the discontinuation of the drug in the course of pregnancy increased the risk of the woman attempting suicide. In the course of comprehensive toxicological analysis based on the developed analytical procedure with the use of LC-APCI-MS, clozapine and its two metabolites, norclozapine and clozapine-N-oxide, were determined in postmortem blood, liver and kidney in concentrations explaining the death of the neonate. The interpretation of the above-described case is complex and--apart from toxicological aspects--also involves issues associated with psychiatry, pharmacotherapy in pregnancy and medicolegal problems.
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Affiliation(s)
- Małgorzata Kłys
- Department of Toxicology, Institute of Forensic Medicine, Collegium Medicum Jagiellonian University, 16 Grzegórzecka St., Kraków, Poland.
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Antia SX, Sholevar EH, Baron DA. Overdoses and ingestions of second-generation antipsychotics in children and adolescents. J Child Adolesc Psychopharmacol 2005; 15:970-85. [PMID: 16379518 DOI: 10.1089/cap.2005.15.970] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE We reviewed the available published data on intentional or unintentional secondgeneration antipsychotic overdoses in children and adolescents. The prescribing of secondgeneration antipsychotics has continued to increase over the past decade for children, adolescents, and adults. The authors reviewed the existing literature to determine the circumstances, presenting problems, treatment, and outcomes of youths who were exposed to nontherapeutic doses of these medications. METHODS A systematic English-language Medline search of all reports (1989-2005) and a review of the bibliographies of all articles obtained was done to identify papers reporting an overdose or ingestion of a second-generation antipsychotic. Data were reviewed on clozapine, risperidone, olanzapine, ziprasidone, quetiapine, and aripiprazole. The annual reports of the American Association of Poison Control Centers National Data Collection System were reviewed from 1990 to 2003, the most recent report currently available. All fatalities in children and youths under 18 years of age were included. RESULTS The literature review identified 40 reports that included 63 patients, ranging in age from 1 day to 17 years of age. The clinical presentations included drowsiness, lethargy, agitation, irritability, combativeness, and tachycardia. There were 11 fatalities in the cases reviewed, 1 from clozapine overdose, 3 from risperidone overdose, 2 from olanzapine overdose, and 5 from quetiapine overdose. All other cases reported no significant sequelae and resolved without any reported clinical consequences. Duration of overdose symptoms ranged from 24 hours to 7 days. One case of clozapine intoxication showed resolution of symptoms in 6 hours and, in another case of olanzapine overdose, symptoms resolved in 13 days. The most frequently employed treatments included intubation, gastric lavage, activated charcoal, intravenous fluids, artificial respiration, and restraints or sedatives. CONCLUSIONS There is a need for future case reports to include serum medication level, weight of patient, coingestants, the health of the patient at baseline, relevant laboratory and toxicology studies and a standardized scale to rate the level of consciousness, such as the Glasgow Coma Scale. The existing pharmacovigilance data reports indicate these medications are relatively safe when taken in overdose, particularly when coingestants are not involved.
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Affiliation(s)
- Smita X Antia
- Department of Psychiatry and Behavioral Sciences, Temple University School of Medicine, Philadelphia, Pennsylvania 19125, USA
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Musshoff F, Padosch S, Steinborn S, Madea B. Fatal blood and tissue concentrations of more than 200 drugs. Forensic Sci Int 2004; 142:161-210. [PMID: 15172079 DOI: 10.1016/j.forsciint.2004.02.017] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fatal drug concentrations in body fluids and tissue samples are presented for more than 200 drugs and chemicals of toxicologic interest. Additionally, a reference list is added with more than 600 original papers concerning intoxications with a lethal outcome. The data can be helpful for the interpretation and plausibility control in own cases of intoxication. However, they should be used with caution, because use of drug data without sufficient knowledge about the patient or victim, the circumstances of the case, and about toxicokinetics and toxicodynamics might give a wrong interpretation in a special case.
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Affiliation(s)
- F Musshoff
- Institute of Legal Medicine, Rheinische Friedrich-Wilhelms-University, Stiftsplatz 12, Bonn 53111, Germany.
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Bartsch C, Risse M, Schütz H, Weigand N, Weiler G. Munchausen syndrome by proxy (MSBP): an extreme form of child abuse with a special forensic challenge. Forensic Sci Int 2003; 137:147-51. [PMID: 14609650 DOI: 10.1016/j.forsciint.2003.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Munchausen syndrome by proxy (MSBP) is a special form of child abuse in which an adult repeatedly produces symptoms of illness in a person under his/her care. In most cases the perpetrators are mothers who repeatedly and in different ways produce or feign symptoms of illness in their children in order to obtain medical treatment for them. MSBP is thus a special form of child abuse that is also of importance in the field of forensic medicine and a particular challenge to the medicolegal expert. We report two cases of poisoning with different substances (clozapine and clonidine) detected by toxicological investigations at our Department of Legal Medicine. The relevance of the problem for the medicolegal expert and the importance of an interdisciplinary co-operation are pointed out.
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Affiliation(s)
- Christine Bartsch
- Department of Legal Medicine, Justus Liebig University, Giessen, Institut für Rechtsmedizin des Universitätsklinikums Giessen, Frankfurter Strasse 58, 35392 Giessen, Germany.
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Garay Garcia L, Forfar-Bares I, Pehourcq F, Jarry C. Simultaneous determination of four antipsychotic drugs in plasma by high-performance liquid chromatography. J Chromatogr B Analyt Technol Biomed Life Sci 2003; 795:257-64. [PMID: 14522030 DOI: 10.1016/s1570-0232(03)00576-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A specific reversed phase-high pressure liquid chromatography (RP-HPLC) method has been developed for the simultaneous determination of clozapine (CZP), loxapine (LXP), zuclopenthixol (ZPT) and flupenthixol (FPT) in plasma. These four antipsychotic drugs are frequently used for the treatment of schizophrenia and other neuropsychiatric diseases. Carpipramine, a dihydrodibenzazepine, was used as an internal standard (I.S.). A liquid-liquid procedure was used to extract the drugs from human plasma. The analysis was performed on a XTerra MS C18 column with UV detection. Calibration curves were linear in the range 50-1000 microg/l. The limit of quantification (LOQ) was 15 microg/l for clozapine and loxapine and 20 microg/l for zuclopenthixol and flupenthixol. The coefficient of variation (CV) for intra- and inter-day precision was 7.2% or less with accuracies within 10% for the three concentrations.This isocratic and rapid method (run time<10 min) is useful for the management of acute intoxication.
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Affiliation(s)
- L Garay Garcia
- EA2962-Pharmacochimie, Université Victor Segalen Bordeaux 2, 146 rue Léo Saignat, Bordeaux Cedex 33076, France
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Abstract
Since 1989, several novel antipsychotic drugs have become available for use including clozapine, risperidone, olanzapine, quetiapine and ziprasidone. These agents represent a substantial improvement in the treatment of schizophrenia and related disorders and are considered to have a favourable adverse effect profile relative to traditional antipsychotics. Nonetheless, in rare cases, people have died as a result of taking atypical antipsychotic drugs at therapeutic and supratherapeutic doses. Toxic doses of atypical antipsychotics are highly variable: some patients have died while taking therapeutic doses and others have survived massive overdoses. Toxicity may be increased by coingestion of other agents, particularly drugs with similar metabolic pathways. Atypical antipsychotics are metabolised predominantly by cytochrome p450 (CYP) isoenzymes, particularly CYP1A2 (clozapine and olanzapine), CYP3A4 (clozapine, quetiapine and ziprasidone) and CYP2D6 (olanzapine and risperidone). Concurrent prescription of other drugs that inhibit these isoenzymes may increase the probability of adverse events in patients taking atypical antipsychotics. Deaths due to atypical antipsychotic toxicity are often related to cardiovascular complications, but pulmonary, neurological, endocrine and gastrointestinal complications have also caused fatalities. Prevention and management of atypical antipsychotic overdose are of increased clinical relevance as prescription of these drugs increases.
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Affiliation(s)
- Adam Trenton
- Department of Psychiatry, University of Rochester School of Medicine, Rochester, New York 14642, USA.
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Flanagan RJ, Amin A, Seinen W. Effect of post-mortem changes on peripheral and central whole blood and tissue clozapine and norclozapine concentrations in the domestic pig (Sus scrofa). Forensic Sci Int 2003; 132:9-17. [PMID: 12689746 DOI: 10.1016/s0379-0738(02)00414-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Interpretation of the results of psychoactive or other drug measurements in post-mortem blood specimens may not be straightforward, in part because analyte concentrations in blood may change after death. There is also the issue of comparability of plasma (or serum) results to those obtained in whole blood. To investigate these problems with respect to clozapine, this drug (10mg/kg daily) was given orally to two pigs. Blood was collected 3h post-dose on day 7, the animals were sacrificed, and blood taken from central and peripheral veins for up to 48 h after death. Tissue samples were also collected immediately after death and at 48 h. Ante-mortem whole blood clozapine/N-desmethylclozapine (norclozapine) concentrations were 0.86/1.07 and 1.11/1.15 mg/l in pigs 1 and 2, respectively. Blood clozapine and norclozapine concentrations generally increased after death (central vein: clozapine up to 300%, norclozapine up to 460%; peripheral vein: clozapine up to 155%, norclozapine up to 185%). Initial blood and kidney clozapine and norclozapine concentrations were comparable in both animals, but were some two-fold higher in heart, liver and striated muscle in pig 2. In both animals, the heart and striated muscle clozapine and norclozapine concentrations had increased some two- to three-fold at 48 h, whilst the liver and kidney concentrations were essentially unchanged. The reason for the increase in heart and striated muscle concentrations at 48 h is unclear, but could be simple variation in sample site. The plasma:whole blood distribution of clozapine and norclozapine was studied in vitro. In human blood (one volunteer donor, haematocrit 0.50) the plots of plasma versus whole blood concentration were linear for both analytes across the range 0.1-1.5mg/l, although clozapine favoured plasma (plasma:whole blood ratio=1.12), whereas norclozapine favoured whole blood (ratio 0.68). In pig blood, the plots of plasma versus whole blood were non-linear in both cases, although clozapine favoured plasma to a greater extent than norclozapine. This may be due to lower plasma clozapine and norclozapine protein binding capacity in the pig as compared to man.
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Affiliation(s)
- R J Flanagan
- Medical Toxicology Unit, Guy's and St Thomas' Hospital Trust, Avonley Road, London SE14 5ER, UK.
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21
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Abstract
As suicides of children, adolescents and young adults occur very seldom and only few case reports and more comprehensive studies are available in forensic literature, the autopsy records of the Bonn Institute of Forensic Medicine and the database of the Bonn police authorities from 1989 to 1998 were retrospectively analysed for this phenomenon. This search revealed 37 respective suicides involving 23 male (62%) and 14 female (38%) victims. The ages ranged from 10 to 21 years with the prevalence sharply increasing in adolescents and young adults. Independent from sex, the victims almost unexceptionally applied hard suicide methods like hanging, running over by a train or jump from the height. As for the psychological background, current conflicts with a sweetheart, within the family or at school on the background of mental illness or chronically disturbed family structures were encountered as prevailing factors.
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Affiliation(s)
- P Schmidt
- Institute of Forensic Medicine, Rheinische Friedrich-Wilhelms-Universität, Stiftspatz 12, D 53111 Bonn, Germany
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22
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Schreinzer D, Frey R, Stimpfl T, Vycudilik W, Berzlanovich A, Kasper S. Different fatal toxicity of neuroleptics identified by autopsy. Eur Neuropsychopharmacol 2001; 11:117-24. [PMID: 11313157 DOI: 10.1016/s0924-977x(01)00068-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Autopsies and toxicological analyses at the Institute of Forensic Medicine revealed 85 fatal intoxications with neuroleptics in Vienna from 1991 to 1997. A total of 17 cases were linked to a single neuroleptic (NL) alone, while 68 deaths were attributed to a combination of NLs with other drugs. The most frequently detected agent was prothipendyl (n=41). During the study period the number of defined daily doses of high-potency NLs prescribed increased significantly (P< or =0.001) due to increased prescribing of new atypical antipsychotics. The quantity of intermediate- and low-potency NLs dispensed remained stable. The most frequently prescribed NL was haloperidol. The relative toxicities of different NLs were calculated by dividing the number of deaths caused by this NL into the number of defined daily doses prescribed in the observation period (f-value). Single-substance intoxications and multiple-substance intoxications were distinguished. The highest f-values were associated with low-potency NLs, especially with prothipendyl, chlorprothixene and levomepromazine. Low f-values were found for the group of high-potency NLs, including flupentixol, fluphenazine, haloperidol and pimozide, as well as olanzapine. Compared to the f-values for all NLs prescribed, f-values for low-potency NLs were shown to be significantly higher concerning single-substance intoxications (P< or = 0.05) and multiple-substance intoxications (P < or = 0.001), while f-values for high-potency NLs were significantly lower (P< or = 0.05 and P< or = 0.001). We are not aware of the psychiatric diagnoses in our post-mortem sample. However, the present results indicate that careless use of low-potent NLs should be avoided in patients with a potential risk of accidental or suicidal overdose.
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Affiliation(s)
- D Schreinzer
- Department of General Psychiatry, University Hospital of Psychiatry, A-1090, Vienna, Austria.
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23
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Renwick AC, Renwick AG, Flanagan RJ, Ferner RE. Monitoring of clozapine and norclozapine plasma concentration-time curves in acute overdose. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2000; 38:325-8. [PMID: 10866334 DOI: 10.1081/clt-100100939] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CASE REPORT A 40-year-old schizophrenic man was found unconscious, with constricted pupils, sinus tachycardia, and twitching of the limbs. There were signs of lung infection, which was treated with antibiotics, and mild rhabdomyolysis. He regained consciousness over 8 hours, and reported taking 3-4 g clozapine. Recovery was uneventful. Measured peak clozapine and norclozapine concentrations were 3.53 mg/L and 0.70 mg/L, respectively. The concentration-time curves were biphasic, with secondary peaks at approximately 36 hours postadmission. Terminal elimination half-lives were 16.9 hours and 22.5 hours for clozapine and norclozapine, respectively. CONCLUSION Clozapine and its metabolite norclozapine can show biphasic plasma concentration-time curves after overdosage.
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24
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Abstract
An ingestion of an unknown quantity of Harmomed (dothiepin and diazepam) capsules in a suicide is described. The authors report a new and fast method of analysing and determining the dothiepin concentration in postmortem specimens. Quantitation of dothiepin, and its metabolite desmethyldothiepin was performed by ethyl acetate extraction from alkalinized body fluids before GC-MS analysis. The analyses were performed without any complex sample clean-up steps and with little sample material. Postmortem concentrations of dothiepin, desmethyldothiepin, diazepam and desmethyldiazepam in body fluids are given. The proposed method is a rapid procedure for analysis in cases of deliberate poisoning with the antidepressant drug dothiepin.
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Affiliation(s)
- T Keller
- Institute of Forensic Medicine, Paris-Lodron-University, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
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25
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Affiliation(s)
- T A Brettell
- Forensic Science Bureau, New Jersey State Police, West Trenton 08625, USA
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26
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Keller T, Schneider A, Lamprecht R, Aderjan R, Tutsch-Bauer E, Kisser W. Fatal chloroquine intoxication. Forensic Sci Int 1998; 96:21-8. [PMID: 9800362 DOI: 10.1016/s0379-0738(98)00105-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A suicidal ingestion of an unknown quantity of Resochin (chloroquine) tablets is described. Although chloroquine is known since 1934, intoxications due to chloroquine overdose are rather rare in European countries. The authors report on a new and fast method of analysing and determining the chloroquine concentration in body fluids and postmortem specimens. The analytes were extracted from alkalinized samples into ethyl acetate before GC/MS analysis. The analyses of chloroquine were performed without any complex sample clean-up steps and, in addition, with little sample material. The proposed method resulted in a rapid procedure most useful in cases of deliberate poisoning with the anti-inflammatory and antimalarial drug chloroquine.
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Affiliation(s)
- T Keller
- Institute of Forensic Medicine, Paris-Lodron-University, Salzburg, Austria
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