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Drevin G, Malbranque S, Jousset N, Férec S, Zabet D, Baudriller A, Briet M, Abbara C. Pharmacobezoar-Related Fatalities: A Case Report and a Review of the Literature. Ther Drug Monit 2024; 46:1-5. [PMID: 37941108 DOI: 10.1097/ftd.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/15/2023] [Indexed: 11/10/2023]
Abstract
ABSTRACT Pharmacobezoars develop after an acute overdose or during routine drug administration. Here, the authors present a case of fatal multidrug overdose involving a 62-year-old woman. Her usual treatment included tramadol extended-release, citalopram, and mirtazapine. Furthermore, she self-medicated and misused her husband's medications. The autopsy revealed the presence of a voluminous medication bezoar in the stomach. No mechanical complication was noted. Toxicologic analyses were performed using gas chromatography with flame ionization detection, liquid chromatography with diode array detection, gas chromatography with mass spectrometry detection, and liquid chromatography coupled to tandem mass spectrometry. Tramadol (34,000 mcg/L), O-desmethyltramadol (2200 mcg/L), propranolol (6000 mcg/L), bromazepam (2500 mcg/L), zopiclone (1200 mcg/L), and citalopram (700 mcg/L) were identified in femoral blood at toxic concentrations. Interestingly, the femoral blood and vitreous humor concentration ratio was approximately 0.7. Furthermore, an English exhaustive literature search was performed using several different electronic databases without any limiting period to identify published pharmacobezoar-related fatalities. Seventeen publications were identified reporting a total of 19 cases. Decedents' mean age was 47.6 years [0.8-79] and a clear female predominance emerged. Several drugs were involved in pharmacobezoar formation. Death was attributed to drug toxicity in 13 cases, and to mechanical complications and/or sepsis in 4 cases. A mixed cause of death was reported in 2 cases. Although rare, pharmacobezoars remain potentially lethal and raise challenges in therapeutic management.
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Affiliation(s)
- Guillaume Drevin
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre Hospitalo-Universitaire, Angers, France
- Université d'Angers, Angers, France
| | - Stéphane Malbranque
- Institut de Médecine légale, Centre Hospitalo-Universitaire, Angers, France; and
| | - Nathalie Jousset
- Université d'Angers, Angers, France
- Institut de Médecine légale, Centre Hospitalo-Universitaire, Angers, France; and
| | - Séverine Férec
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre Hospitalo-Universitaire, Angers, France
| | - Donca Zabet
- Institut de Médecine légale, Centre Hospitalo-Universitaire, Angers, France; and
| | - Antoine Baudriller
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre Hospitalo-Universitaire, Angers, France
| | - Marie Briet
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre Hospitalo-Universitaire, Angers, France
- Université d'Angers, Angers, France
- Laboratoire MitoVasc, UMR CNRS 6214 INSERM 1083, Angers, France
| | - Chadi Abbara
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre Hospitalo-Universitaire, Angers, France
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Santunione AL, Palazzoli F, Verri P, Vandelli D, Castagnetti V, Profeta C, Silingardi E. Cardiovascular drugs and suicide death: Determination of carvedilol, amlodipine, doxazosin and diltiazem in two fatal cases. J Pharm Biomed Anal 2024; 238:115831. [PMID: 37980865 DOI: 10.1016/j.jpba.2023.115831] [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: 08/24/2023] [Revised: 10/27/2023] [Accepted: 10/29/2023] [Indexed: 11/21/2023]
Abstract
A number of medical conditions are identified as risk factors for suicide death; in particular, cardiovascular illnesses are recognized as a major suicide risk factor. In this case, self-poisoning is the common method of suicide and cardiovascular drugs are among the major medications associated with fatal overdose, with calcium channel blockers being one of the most common agents. The present study describes two different fatal suicide cases involving four cardiovascular drugs: carvedilol, doxazosin and amlodipine (case 1) and diltiazem (case 2). The concentrations of the target cardiovascular drugs in the different biological specimens (central and femoral blood, urine, liver, brain) are presented, giving information about the potentially fatal data and the distribution of the drugs in the body. The study led to the implementation of a fast, sensitive and simple method for the detection and quantification of the four commonly prescribed cardiovascular drugs in post-mortem specimens including fluids and tissues for forensic purposes. The method was fully validated. The toxicological results of the studied cases are discussed, along with the autopsy results, histopathological evidence, and circumstances of death. The toxicological findings presented in the study provide new data regarding cardiovascular drugs in different post-mortem specimens, which will contribute to the currently limited knowledge about the toxicological profile of cardiovascular drugs and their distribution.
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Affiliation(s)
- A L Santunione
- Department of Biomedical, Metabolic and Neural Sciences, Institute of Legal Medicine, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy.
| | - F Palazzoli
- Department of Biomedical, Metabolic and Neural Sciences, Institute of Legal Medicine, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
| | - P Verri
- Department of Biomedical, Metabolic and Neural Sciences, Institute of Legal Medicine, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
| | - D Vandelli
- Department of Biomedical, Metabolic and Neural Sciences, Institute of Legal Medicine, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
| | - V Castagnetti
- Department of Biomedical, Metabolic and Neural Sciences, Institute of Legal Medicine, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
| | - C Profeta
- Department of Biomedical, Metabolic and Neural Sciences, Institute of Legal Medicine, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
| | - E Silingardi
- Department of Biomedical, Metabolic and Neural Sciences, Institute of Legal Medicine, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
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Rosell-Hidalgo A, Bruhn C, Shardlow E, Barton R, Ryder S, Samatov T, Hackmann A, Aquino GR, Fernandes Dos Reis M, Galatenko V, Fritsch R, Dohrmann C, Walker PA. In-depth mechanistic analysis including high-throughput RNA sequencing in the prediction of functional and structural cardiotoxicants using hiPSC cardiomyocytes. Expert Opin Drug Metab Toxicol 2023:1-23. [PMID: 37995132 DOI: 10.1080/17425255.2023.2273378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/15/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Cardiotoxicity remains one of the most reported adverse drug reactions that lead to drug attrition during pre-clinical and clinical drug development. Drug-induced cardiotoxicity may develop as a functional change in cardiac electrophysiology (acute alteration of the mechanical function of the myocardium) and/or as a structural change, resulting in loss of viability and morphological damage to cardiac tissue. RESEARCH DESIGN AND METHODS Non-clinical models with better predictive value need to be established to improve cardiac safety pharmacology. To this end, high-throughput RNA sequencing (ScreenSeq) was combined with high-content imaging (HCI) and Ca2+ transience (CaT) to analyze compound-treated human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). RESULTS Analysis of hiPSC-CMs treated with 33 cardiotoxicants and 9 non-cardiotoxicants of mixed therapeutic indications facilitated compound clustering by mechanism of action, scoring of pathway activities related to cardiomyocyte contractility, mitochondrial integrity, metabolic state, diverse stress responses and the prediction of cardiotoxicity risk. The combination of ScreenSeq, HCI and CaT provided a high cardiotoxicity prediction performance with 89% specificity, 91% sensitivity and 90% accuracy. CONCLUSIONS Overall, this study introduces mechanism-driven risk assessment approach combining structural, functional and molecular high-throughput methods for pre-clinical risk assessment of novel compounds.
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Affiliation(s)
- Alicia Rosell-Hidalgo
- The authors contributed equally to this work
- Cyprotex Discovery Ltd UK, Macclesfield, UK
| | - Christopher Bruhn
- The authors contributed equally to this work
- Evotec International GmbH, Göttingen, Germany
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Solvent bar microextraction combined with HPLC-DAD and multivariate optimization for simultaneous determination of three antiarrhythmic drugs in human urine and plasma samples. TALANTA OPEN 2022. [DOI: 10.1016/j.talo.2022.100140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kvachakhia LL, Shormanov VK. [Amlodipine assay conditions and stability in biological material]. Sud Med Ekspert 2022; 65:46-50. [PMID: 35947410 DOI: 10.17116/sudmed20226504146] [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] [Indexed: 06/15/2023]
Abstract
The objective of the study is to determine amlodipine assay conditions and stability in biological material. Thin layer chromatography (TLC), gas chromatography-mass spectrometry (GC-MS) and UV-spectrophotometry were used for identification. Amlodipine was recovered from biomaterial by double (30 min each) infusing with acetone at the ratio of recovery solution and sample 2:1 (w/w). The purification was carried out by extraction and chromatography in a semi-preparative column with reverse-phase packing material Silasorb C-18 using acetone/water eluent (8:2). Amlodipine assay was performed by TLC [Sorbfil plates, butanol/acetone (5:5) as a mobile phase], GC-MS (HP-5 ms Ultra inert column (30 m×0.25×0.25 μm) with stationary phase of 5% phenyl-95% dimethyl polysiloxane), UV-spectrophotometry (95% ethanol as a solvent). The proposed assay method for amlodipine in biomaterial (liver tissue) is validated for linearity, selectivity, accuracy and precision. The amlodipine stability in model mixtures with liver tissue was studied. It was shown that the analyte stability in biological material decreases with increasing temperature. Amlodipine is stable at -25 °C, 0-2 °C, 8-10 °C, 18-22 °C, and 36 °C for 120, 112, 105, 91, and 77 days, respectively.
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Gish A, Onimus T, Durand A, Goutay J, Hennart B, Hakim F, Castex E, Richeval C, Wiart JF, Humbert L, Allorge D, Gaulier JM. Intoxication sévère par cardiotropes avec suivi en temps réel des concentrations sanguines. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2021. [DOI: 10.1016/j.toxac.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fabresse N, Larabi IA, Lamy E, Mégarbane B, Alvarez JC. Molecular adsorbent recirculating system (MARS) and continuous veno-venous hemodiafiltration (CVVHDF) for diltiazem removal: An in vitro study. Int J Artif Organs 2020; 44:489-496. [PMID: 33258721 DOI: 10.1177/0391398820975041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of the present study was to evaluate the efficacy of the molecular adsorbent recirculating system (MARS) vs continuous veno-venous hemodiafiltration (CVVHDF). Diltiazem poisoning was simulated in a central compartment consisting in a 5L dialysis solute spiked with diltiazem at two different toxic concentrations: 750 and 5000 µg/L. For CVVHDF, mean extraction coefficients (EC = (in concentration - out concentration)/in concentration) were concentration-dependent with a decrease all along the dialysis. At the end of the sessions the mean amounts remaining in the central compartment were 8% and 7% of the initial dose at 750 and 5000 µg/L, respectively. The mean cumulative amounts found in the effluent were 60% and 75% of the initial dose, respectively. The missing amounts accounted for 32% and 18% of the initial dose, respectively, corresponding to an adsorption to the dialysis membrane. In contrast, the different compartments of the MARS resulted in undetectable output concentration earlier that the end of the session. The mean concentrations of diltiazem remaining in the central compartment were <1 µg/L at the end of the sessions. Global ECs were around 50% all along the experiment at both concentrations, and the average charcoal cartridge ECs was 80% throughout the experiments.CVVHDF system in the developed model was efficient for diltiazem removal, mainly by diffusion, convection and to a lesser extent by adsorption to the dialysis membrane. In MARS system, resin cartridge and hemodialysis components are ineffective, charcoal cartridge is responsible for almost all drug removal.
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Affiliation(s)
- Nicolas Fabresse
- MassSpecLab, Plateforme de Spectrométrie de Masse, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France.,Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, Garches, France
| | - Islam Amine Larabi
- MassSpecLab, Plateforme de Spectrométrie de Masse, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France.,Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, Garches, France
| | - Elodie Lamy
- MassSpecLab, Plateforme de Spectrométrie de Masse, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France
| | - Bruno Mégarbane
- Réanimation Toxicologique, Centre Hospitalier Universitaire Lariboisière, Paris, France
| | - Jean-Claude Alvarez
- MassSpecLab, Plateforme de Spectrométrie de Masse, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France.,Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, Garches, France
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Alvarez JC, Mayer-Duverneuil C, Cappy J, Lorin de la Grandamison G, Knapp-Gisclon A. Postmortem fatal and non-fatal concentrations of amlodipine. Forensic Sci Int 2020; 316:110555. [PMID: 33152659 DOI: 10.1016/j.forsciint.2020.110555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 11/29/2022]
Abstract
Amlodipine is a dihydropyridine calcium channel blocker widely used in the treatment of high blood pressure and coronary heart disease. Intoxication can lead to reflex tachycardia following massive hypotension and death. The objective of this work was to study the post-mortem concentrations of amlodipine in 62 patients in order to determine whether the use of the reference concentrations from the living patients was applicable in postmortem setting, and to define more precisely the fatal and non-fatal postmortem concentrations of amlodipine. The amlodipine concentrations were measured in femoral whole blood by LC-MS/MS validated method. When sufficient information was available, the data were classified into 2 different groups, based on the conclusions of the autopsy and toxicological results: G1: non-toxic death and G2: fatal poisoning involving amlodipine alone or as part of a multidrug poisoning. The median concentration of amlodipine [1st quartile - 3rd quartile] of the whole population (n = 62) was 81 [42-134] ng/mL. Twenty-two cases were classified as G1 and thirteen as G2. The observed median [1st quartile - 3rd quartile] concentration of amlodipine was 66 [40.5-79.5] ng/mL in G1 and 240 [170-404] ng/mL in G2. The median concentrations observed in "non-toxic" deaths (66 ng/mL) were three times higher than those usually observed in living patients. Amlodipine distribution ratio between plasma and whole blood concentrations seems insufficient to explain this difference and postmortem redistribution from organs should be considered, and could suggest the same redistribution pattern for other drugs belonging to the same family.
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Affiliation(s)
- J C Alvarez
- Laboratoire de Pharmacologie - Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, 104 boulevard Raymond Poincaré, 92380, Garches, France; Plateforme de Spectrométrie de Masse MassSpecLab, INSERM UMR 1173, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, 2 avenue de la source de la Bièvre, 78180, Montigny le Bretonneux, France.
| | - C Mayer-Duverneuil
- Laboratoire de Pharmacologie - Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - J Cappy
- Institut de Médecine Légale, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - G Lorin de la Grandamison
- Institut de Médecine Légale, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - A Knapp-Gisclon
- Laboratoire de Pharmacologie - Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, 104 boulevard Raymond Poincaré, 92380, Garches, France
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Basílio F, Dinis-Oliveira RJ. Clinical and Forensic Aspects of Pharmacobezoars. Curr Drug Res Rev 2020; 12:118-130. [PMID: 32065097 DOI: 10.2174/2589977512666200217094018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/25/2020] [Accepted: 01/28/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pharmacobezoars are specific types of bezoars formed when medicines, such as tablets, suspensions, and/or drug delivery systems, aggregate and may cause death by occluding airways with tenacious material or by eluting drugs resulting in toxic or lethal blood concentrations. OBJECTIVE This work aims to fully review the state-of-the-art regarding pathophysiology, diagnosis, treatment, and other relevant clinical and forensic features of pharmacobezoars. RESULTS Patients of a wide range of ages and of both sexes present with signs and symptoms of intoxications or more commonly gastrointestinal obstructions. The exact mechanisms of pharmacobezoar formation are unknown but are likely multifactorial. The diagnosis and treatment depend on the gastrointestinal segment affected and should be personalized to the medication and the underlying factor. A good and complete history, physical examination, image tests, upper endoscopy, and surgery through laparotomy of the lower tract are useful for diagnosis and treatment. CONCLUSION Pharmacobezoars are rarely seen in clinical and forensic practice. They are related to controlled or immediate-release formulations, liquid, or non-digestible substances, in normal or altered digestive motility/anatomy tract, and in overdoses or therapeutic doses, and should be suspected in the presence of risk factors or patients taking drugs which may form pharmacobezoars.
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Affiliation(s)
- Francisco Basílio
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ricardo Jorge Dinis-Oliveira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
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