A novel system for the determination of antidepressant concentrations in human breast milk

Drugs in Human Milk Part 1: Practical and Analytical Considerations in Measuring Drugs and Metabolites in Human Milk

Human milk is a remarkable biofluid that provides essential nutrients and immune protection to newborns. Breastfeeding women consuming medications could pass the drug through their milk to neonates. Drugs can be transferred to human milk by passive diffusion or active transport. The physicochemical properties of the drug largely impact the extent of drug transfer into human milk. A comprehensive understanding of the physiology of human milk formation, composition of milk, mechanisms of drug transfer, and factors influencing drug transfer into human milk is critical for appropriate selection and use of medications in lactating women. Quantification of drugs in the milk is essential for assessing the safety of pharmacotherapy during lactation. This can be achieved by developing specific, sensitive, and reproducible analytical methods using techniques such as liquid chromatography coupled with mass spectrometry. The present review briefly discusses the physiology of human milk formation, composition of human milk, mechanisms of drug transfer into human milk, and factors influencing transfer of drugs from blood to milk. We further expand upon and critically evaluate the existing analytical approaches/assays used for the quantification of drugs in human milk.

Simultaneous quantification of fluoxetine and norfluoxetine in colostrum and mature human milk using a 2-dimensional liquid chromatography-tandem mass spectrometry system

A two-dimensional liquid chromatography system coupled to triple quadrupole tandem mass spectrometer (2D LC-MS/MS) was employed for the determination of fluoxetine (FLU) and norfluoxetine (N-FLU) in colostrum and mature milk by direct sample injection. With a run time of 12 min representing a gain in throughput analysis, the validated methods furnished selectivity, extraction efficiency, accuracy, and precision in accordance with the criteria preconized by the European Medicines Agency guidelines. With a linear range of 3.00-150 ng/mL for FLU and 4.00-200 ng/mL for N-FLU they were applied to the analysis of colostrum and mature milk samples from nursing mothers. The paper discusses the differences and similarity of sample preparation for this two sample matrices. The herein reported methods are an advance in sample preparation procedures providing waste reduction and a sustainable approach.

Paroxetine hydrochloride

Paroxetine hydrochloride (3S-trans)-3-[(1,3-benzodioxol-5-yloxy)methyl]-4-(4-fluorophenyl)-piperidine hydrochloride (or (-)-(3S,4R)-(4-(p-fluorophenyl)-3-[[3,4-(methylenedioxy)-phenoxy]methyl]piperidine hydrochloride), a phenylpiperidine derivative, is a selective serotonin reuptake inhibitor. Paroxetine is indicated for the treatment of depression, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, and social anxiety disorder. The physicochemical properties, spectroscopic data (1D and 2D NMR, UV, FT-IR, MS, PXRD), stability, methods of preparation and chromatographic methods of analysis of pharmaceutical, and biological samples of paroxetine are documented in this review. Pharmacokinetics, metabolism, and pharmacological effects are also discussed.

Predictors of remission in depression to individual and combined treatments (PReDICT): study protocol for a randomized controlled trial

BACKGROUND

Limited controlled data exist to guide treatment choices for clinicians caring for patients with major depressive disorder (MDD). Although many putative predictors of treatment response have been reported, most were identified through retrospective analyses of existing datasets and very few have been replicated in a manner that can impact clinical practice. One major confound in previous studies examining predictors of treatment response is the patient's treatment history, which may affect both the predictor of interest and treatment outcomes. Moreover, prior treatment history provides an important source of selection bias, thereby limiting generalizability. Consequently, we initiated a randomized clinical trial designed to identify factors that moderate response to three treatments for MDD among patients never treated previously for the condition.

METHODS/DESIGN

Treatment-naïve adults aged 18 to 65 years with moderate-to-severe, non-psychotic MDD are randomized equally to one of three 12-week treatment arms: (1) cognitive behavior therapy (CBT, 16 sessions); (2) duloxetine (30-60 mg/d); or (3) escitalopram (10-20 mg/d). Prior to randomization, patients undergo multiple assessments, including resting state functional magnetic resonance imaging (fMRI), immune markers, DNA and gene expression products, and dexamethasone-corticotropin-releasing hormone (Dex/CRH) testing. Prior to or shortly after randomization, patients also complete a comprehensive personality assessment. Repeat assessment of the biological measures (fMRI, immune markers, and gene expression products) occurs at an early time-point in treatment, and upon completion of 12-week treatment, when a second Dex/CRH test is also conducted. Patients remitting by the end of this acute treatment phase are then eligible to enter a 21-month follow-up phase, with quarterly visits to monitor for recurrence. Non-remitters are offered augmentation treatment for a second 12-week course of treatment, during which they receive a combination of CBT and antidepressant medication. Predictors of the primary outcome, remission, will be identified for overall and treatment-specific effects, and a statistical model incorporating multiple predictors will be developed to predict outcomes.

DISCUSSION

The PReDICT study's evaluation of biological, psychological, and clinical factors that may differentially impact treatment outcomes represents a sizeable step toward developing personalized treatments for MDD. Identified predictors should help guide the selection of initial treatments, and identify those patients most vulnerable to recurrence, who thus warrant maintenance or combination treatments to achieve and maintain wellness.

Antidepressants in pregnancy: a review of commonly prescribed medications

Perinatal depression is an increasingly common comorbidity of pregnancy and is associated with adverse birth outcomes. Newer classes of antidepressants have been developed with a variety of mechanisms and improved side effect profiles. There is increasing use of these medications in reproductive-aged women. Medical providers have to balance the need to prevent relapse of maternal depressive symptoms with the need to minimize fetal exposure to medications. We review the literature on 10 of the most commonly used antidepressant medications: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine, duloxetine, bupropion, and mirtazapine. The pharmacokinetic properties of the medications are detailed, as well as practical considerations for their use in pregnant and lactating women. Guidance on counseling and management of pregnancies complicated by perinatal depression is discussed.

TARGET AUDIENCE

Obstetricians & Gynecologists and Family Physicians.

LEARNING OBJECTIVES

After completing this CME activity, physicians should be better able to differentiate the current classes of medications utilized commonly for perinatal depression, evaluate the reported adverse effects of antidepressant medications on the patient and developing fetus and choose the appropriate antidepressant medications for a depressed patient who is breast-feeding.

Bio-sample preparation and analytical methods for the determination of tricyclic antidepressants

An extended and comprehensive review is presented herein, focusing on sample preparation (pretreatment and extraction) and different analytical methods applied for the quantification of tricyclic antidepressants. These procedures are relevant tools in clinical and forensic toxicology. It is revealed that SPE, for sample preparation, and HPLC, using reversed-phase alkyl (C18) or cyanopropyl-bonded silica columns for the analytes separation, are effective and versatile methods for assay of tricyclic antidepressants. These methods enable achievable detection limits using UV/diode array detection, readily available in most laboratories, down to 1–8 ng ml-1, and using electron capture detection better than 1 ng ml-1, which is lower than that for nitrogen–phosphorus detector. MS interfaced with electrospray ionization offered similar sensitivity, whilst sonic spray ionization provided detection down to 0.03 ng ml-1. A brief discussion on chemical structures, metabolism and mechanism of action of this group of drugs is also presented.

A novel electrochemical sensor for probing doxepin created on a glassy carbon electrode modified with poly(4-amino- benzoic acid)/multi-walled carbon nanotubes composite film

A novel electrochemical sensor for sensitive detection of doxepin was prepared, which was based on a glassy carbon electrode modified with poly(4-aminobenzoic acid)/multi-walled carbon nanotubes composite film [poly(4-ABA)/MWNTs/GCE]. The sensor was characterized by scanning electron microscopy and electrochemical methods. It was observed that poly(4-ABA)/MWNTs/GCE showed excellent preconcentration function and electrocatalytic activities towards doxepin. Under the selected conditions, the anodic peak current was linear to the logarithm of doxepin concentration in the range from 1.0 × 10⁻⁹ to 1.0 × 10⁻⁶ M, and the detection limit obtained was 1.0 × 10⁻¹⁰ M. The poly(4-ABA)/MWNTs/GCE was successfully applied in the measurement of doxepin in commercial pharmaceutical formulations, and the analytical accuracy was confirmed by comparison with a conventional ultraviolet spectrophotometry assay.

Antidepressant medication use during breastfeeding

We performed an electronic search by using MEDLINE, PreMEDLINE, Current Contents, Biological Abstracts, and PsycINFO from June 2002 to December 2008 using the following terms: "antidepressant drugs", "antidepressive agents", "human milk", "lactation", and "breastfeeding" and the generic name of each antidepressant. Articles in the English language with reports of antidepressants in maternal serum or breast milk, infant serum, and short-term and long-term clinical outcomes in the infants were obtained. The search yielded a total of 31 empirical papers. Breastfeeding and antidepressant treatments are not mutually exclusive. Sertraline, paroxetine, nortriptyline, and imipramine are the most evidence-based medications for use during breastfeeding.

Rapid HPLC method for the simultaneous monitoring of duloxetine, venlaflaxine, fluoxetine and paroxetine in biofluids

A simple and rapid HPLC method is developed for the determination of two serotonin–norepinephrine-reuptake inhibitors (duloxetine and venlaflaxine) and two selective serotonin-reuptake inhibitors (fluoxetine and paroxetine) in human biofluids. Separation was performed on an Inertsil ODS-3 column (250 x 4.0 mm, 5 µm) with acetonitrile–ammonium acetate (0.05 M, 41:59 v/v) at 235 nm, within 7 min. SPE on Oasis® HLB cartridges was applied for the isolation of analytes from biofluids. The developed methodology was validated in terms of sensitivity, linearity, accuracy, precision, stability and selectivity. Relative standard deviation was less than 10.4%. Limit of detection was 0.2–0.6 ng/µl in blood plasma and 0.1–0.8 ng/µl in urine. The method was successfully applied to biofluids from a patient under duloxetine treatment.

Second-derivative synchronous fluorescence spectroscopy for the simultaneous determination of fluphenazine hydrochloride and nortriptyline hydrochloride in pharmaceutical preparations

A rapid, simple, and highly sensitive second-derivative synchronous fluorimetric (SDSF) method has been developed for the simultaneous analysis of binary mixtures of fluphenazine hydrochloride (FLZ) and nortriptyline hydrochloride (NTP) in their co-formulated tablets. The method is based upon measurement of the native fluorescence of these drugs at constant wavelength difference (Deltalambda) = 120 nm in acetic acid. The different experimental parameters affecting the fluorescence intensity of the studied drugs were carefully studied and optimized. The fluorescence-concentration plots were rectilinear over the range of 0.25-3.0 and 1-10 microg/ml for FLZ and NTP respectively, with lower detection limits (LOD) of 0.05 and 0.18 microg/ml and quantitation limits of 0.15 and 0.53 microg/ml for FLZ and NTP respectively. The proposed method was successfully applied for the determination of the studied compounds in their synthetic mixtures and in commercial co-formulated tablets. The results obtained were in good agreement with those obtained by the reference methods.

Modern bioanalytical methods for the rapid detection of antidepressants: SNRIs and SSRIs in human biological samples

Serotonin–norepinephrine-reuptake inhibitors (SNRIs) and selective serotonin-reuptake inhibitors (SSRIs) belong to a new generation of antidepressants used in the treatment of depression and other mood disorders. SSRIs act as reuptake inhibitors primarily via the inhibition of the neuronal reuptake of serotonin (5-HT) in the CNS. SNRIs have additional inhibitory activity at noradrenaline-reuptake sites. Different analytical methods for the routine monitoring and toxicological screening of SNRIs and SSRIs have been developed. Rapid quantification is a necessity for clinical use, allowing the possibility of diagnostics. This review focuses on recent advances of the methods that concern the determination of SSRIs and SNRIs in human biological samples. Sample preparation methodologies are discussed, because sample pretreatment is the most limiting and crucial step in analysis of biological matrices. Furthermore, information concerning the mechanism of action, side effects and toxicity are also given.

Lamotrigine in breast milk and nursing infants: determination of exposure

OBJECTIVE

Although lamotrigine use during pregnancy has substantially increased over the past decade secondary to accumulated reproductive safety data, systematic data on lamotrigine during breastfeeding remains sparse. We sought to characterize the determinants of lamotrigine concentrations in breast milk and nursing-infant plasma.

PATIENTS AND METHODS

Women who enrolled in a prospective investigation of perinatal medication pharmacokinetics, were treated with lamotrigine, and chose to continue lamotrigine while breastfeeding were included in the analysis. Breast milk samples were collected via breast pump from foremilk to hindmilk from a single breast to determine the excretion gradient and serial samples over 24 hours to determine the time course of excretion. Paired maternal/infant plasma samples were also collected. Lamotrigine concentrations in all of the samples were determined by using high-performance liquid chromatography with ultraviolet detection. Statistical analyses of breast milk and infant plasma concentrations and their determinants were conducted.

RESULTS

Thirty women and their nursing infants participated in the study, providing a total of 210 breast milk samples. The mean milk/plasma ratio was 41.3%. There was a nonsignificant trend for higher lamotrigine concentrations in breast milk 4 hours after the maternal dose. Infant plasma concentrations were 18.3% of maternal plasma concentrations. The theoretical infant lamotrigine dose was 0.51 mg/kg per day, and the relative infant lamotrigine dose was 9.2%. Mild thrombocytosis was present in 7 of 8 infants at the time of serum sampling. No other adverse events were observed or reported in the breastfed infants.

CONCLUSIONS

Consistent with previous investigations of medications in breast milk, the lamotrigine milk/plasma ratio is highly variable. The rate of lamotrigine excretion into human breast milk is similar to that observed with other antiepileptic drugs. These data expand the extant literature on lamotrigine in breastfeeding and demonstrate relatively comparable nursing-infant exposure to lamotrigine compared with other antiepileptic drugs.

Breastfeeding and antidepressants

Although a large literature supports the benefits of breastfeeding, this review suggests that breastfeeding is less common among postpartum depressed women, even though their infants benefit from the breastfeeding. Depressed mothers, in part, do not breastfeed because of their concern about potentially negative effects of antidepressants on their infants. Although sertraline (Zoloft) and paroxetine (Paxol) concentrations are not detectable in infants' sera, fluoxetine (Prozac) and citalopram (Celexa) do have detectable levels. Unfortunately these findings are not definitive because they are based on very small sample, uncontrolled studies. As in the literature on prenatal antidepressant effects, the question still remains whether the antidepressants or the untreated depression itself has more negative effects on the infant. It is possible that the positive effects of breastfeeding may outweigh the positive effects of the antidepressants for both the mother and the infant. In addition, some alternative therapies may substitute or attenuate the effects of antidepressants, such as vagal stimulation or massage therapy, both therapies being noted to reduce depression. Further studies of this kind are needed to determine the optimal course of therapy for the benefit of the depressed, breastfeeding mother and the breastfed infant.

Comparison of electron and chemical ionization modes by validation of a quantitative gas chromatographic-mass spectrometric assay of new generation antidepressants and their active metabolites in plasma

A gas chromatographic-mass spectrometric method (GC-MS) for the simultaneous determination of the 'new' antidepressants (mirtazapine, viloxazine, venlafaxine, trazodone, citalopram, mianserin, reboxetine, fluoxetine, fluvoxamine, sertraline, maprotiline, melitracen, paroxetine) and their active metabolites (desmethylmirtazapine, O-desmethylvenlafaxine, m-chlorophenylpiperazine, desmethylcitalopram, didesmethylcitalopram, desmethylmianserin, desmethylfluoxetine, desmethylsertraline, desmethylmaprotiline) in plasma using different ionization modes was developed and validated. Sample preparation consisted of a strong cation exchange mechanism and derivatisation with heptafluorobutyrylimidazole. The GC separation was performed in 24.8 min. Identification and quantification were based on selected ion monitoring in electron (EI) and chemical ionization (CI) modes. Calibration by linear and quadratic regression for electron and chemical ionization, respectively, utilized deuterated internal standards and a weighing factor 1/x(2). Limits of quantitation were established between 5 and 12.5 ng/ml in EI and positive ionization CI (PICI), and 1 and 6.25 ng/ml in negative ionization CI (NICI). During validation stability, sensitivity, precision, accuracy, recovery, and selectivity were evaluated for each ionization mode and were demonstrated to be acceptable for most compounds. While it is clear that not all compounds can be quantitated either due to chromatographic (trazodone) or derivatisation problems (O-desmethylvenlafaxine), this method can quantitate most new antidepressants (ADs) in the therapeutic range using EI. PICI and NICI lead to higher selectivity. Moreover, NICI is of interest for small sample volumes and high sensitivity requirements. This paper draws the attention to the pros and cons of the different ionization modes in the GC-MS analysis of these antidepressants in plasma.

Electroanalytical determination of paroxetine in pharmaceuticals

Electroanalytical methods based on square-wave adsorptive-stripping voltammetry (SWAdSV) and flow-injection analysis with SWAdSV detection (FIA-SWAdSV) were developed for the determination of paroxetine (PRX). The methods were based on the reduction of PRX at a mercury drop electrode at -1.55V versus Ag/AgCl, in a borate buffer of pH 8.8, and the possibility of accumulating the compound at the electrode surface. Because the presence of dissolved oxygen did not interfere significantly with the analysis, it was also possible to determine PRX using FIA-SWAdSV. This method enables analysis of up to 120 samples per hour at reduced costs. Both methods developed were validated and successfully applied to the quantification of PRX in pharmaceutical products.