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Maskell PD. Just say no to postmortem drug dose calculations. J Forensic Sci 2021; 66:1862-1870. [PMID: 34302366 DOI: 10.1111/1556-4029.14801] [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: 04/16/2021] [Revised: 05/22/2021] [Accepted: 06/30/2021] [Indexed: 11/27/2022]
Abstract
For years, a number of professional groups have warned forensic and clinical toxicologists against calculating an administered dose of a drug based on postmortem blood drug concentrations. But to date, there has been limited information as to how unreliable these dose calculations may actually be. Using amitriptyline as a model drug, this study used empirically determined pharmacokinetic variables for amitriptyline from clinical studies coupled with clinical overdoses (where the individual survived), and death case studies (ascribed to amitriptyline toxicity) in which the dose of amitriptyline was known. Using these data, standard pharmacokinetic equations, and general error propagation, it was possible to estimate the accuracy of calculated doses of amitriptyline, compared with the doses that were consumed. As was expected in postmortem cases, depending on the pharmacokinetic equation used, the accuracy (mean +128% to +2347%) and precision (SD ± 383% to 3698%) were too large to allow reliable estimations of the dose of amitriptyline consumed prior to death based on postmortem blood drug concentrations. This work again reinforces that dose calculations from postmortem blood drug concentrations are unreliable.
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Affiliation(s)
- Peter D Maskell
- Forensic Medicine and Science, University of Glasgow, Glasgow, UK
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2
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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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Mikkelsen CR, Jornil JR, Andersen LV, Banner J, Hasselstrøm JB. Distribution of Eight QT-Prolonging Drugs and Their Main Metabolites Between Postmortem Cardiac Tissue and Blood Reveals Potential Pitfalls in Toxicological Interpretation. J Anal Toxicol 2019; 42:375-383. [PMID: 29579279 DOI: 10.1093/jat/bky018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/12/2018] [Indexed: 12/13/2022] Open
Abstract
Femoral blood concentrations are usually used in postmortem toxicology to assess possible toxic effects of drugs. This includes QT-prolongation and other cardiac dysrhythmia, which could have been the cause of death. However, blood concentration is only a surrogate for the active site concentration, and therefore cardiac tissue concentration may provide a more accurate toxicological interpretation. Thus, cardiac tissue and femoral and cardiac blood concentrations were examined for eight frequently used QT-prolonging drugs (QTD) and their metabolites in a mentally ill population. In total, 180 cases were included from the Danish autopsy-based forensic study SURVIVE. The concentrations were analyzed using ultra-performance liquid chromatography coupled with tandem mass spectrometry utilizing stable isotopically labeled internal standards. The results showed that the cardiac tissue concentrations were significantly higher compared to femoral and cardiac blood concentrations, with two exceptions. The median cardiac tissue-to-femoral blood concentration ratio (Kb) ranged from 2.2 (venlafaxine) to 15 (nortriptyline). The inter-individual fold difference between the minimum and maximum Kb ranged from 2.6-fold (Z-hydroxynortriptyline) to 61 (venlafaxine). For 12 compounds, postmortem redistribution appeared to be minimal, whereas four compounds displayed some degree of postmortem redistribution. Citalopram and quetiapine were selected for in-depth analysis of the relation between the toxicological interpretation and femoral blood/cardiac tissue concentrations. Within this dataset, citalopram displayed a wide overlap in cardiac tissue concentrations (~50%) between non-toxic and toxic citalopram cases, as estimated from femoral blood concentrations. In contrast, quetiapine displayed no overlap in cardiac tissue concentrations between non-toxic and toxic quetiapine cases based on femoral blood concentrations. The implication of the citalopram finding is that possible intoxications can be overlooked when only considering femoral blood concentrations. Based on the present findings, non-toxic cardiac tissue 10th-90th percentile concentration ranges were estimated for citalopram (0.93-4.4 mg/kg) and quetiapine (0.0073-0.60 mg/kg).
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Affiliation(s)
- Christian R Mikkelsen
- Section of Forensic Chemistry, Department of Forensic Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
| | - Jakob R Jornil
- Section of Forensic Chemistry, Department of Forensic Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
| | - Ljubica V Andersen
- Section of Forensic Chemistry, Department of Forensic Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark.,Department of Clinical Pharmacology, Aarhus University, Wilhelm Meyers Allé 4, Aarhus C, Denmark
| | - Jytte Banner
- Section of Forensic Pathology, Department of Forensic Medicine, University of Copenhagen, Frederik V's Vej 11, Copenhagen, Denmark
| | - Jørgen B Hasselstrøm
- Section of Forensic Chemistry, Department of Forensic Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
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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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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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Lewis RJ, Angier MK, Williamson KS, Johnson RD. Analysis of Sertraline in Postmortem Fluids and Tissues in 11 Aviation Accident Victims. J Anal Toxicol 2013; 37:208-16. [DOI: 10.1093/jat/bkt014] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Howell BA, Chauhan A. A Physiologically Based Pharmacokinetic (PBPK) Model for Predicting the Efficacy of Drug Overdose Treatment With Liposomes in Man. J Pharm Sci 2010; 99:3601-19. [DOI: 10.1002/jps.22115] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Margalho C, Barroso M, Gallardo E, Monsanto P, Vieira DN. Massive intoxication involving unusual high concentration of amitriptyline. Hum Exp Toxicol 2007; 26:667-70. [PMID: 17884955 DOI: 10.1177/0960327107076813] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Amitriptyline is a tricyclic antidepressant widely used in the treatment of depression. Antidepressant drugs are among the most commonly encountered causes of self-poisoning, as illustrated by several published cases in the literature. This investigation reports a case of massive amitriptyline intoxication, involving a 44-year old female found dead in bed. The presence of this tricyclic antidepressant was revealed by a routine screening procedure. The concentration was calculated by gas chromatography/ electron ionization-mass spectrometry in the selected ion monitoring mode after solid-phase extraction using proadifen as internal standard and was in the post-mortem whole blood sample 85.9 mug/mL. This value was much higher than the reported toxic values ever found in the literature, and may therefore have caused the victim's death. Nortriptyline was also detected in the toxic concentration range, as well as therapeutic levels of diazepam and nor-diazepam. Taking into account both the available circumstantial information and toxicological results, it is very likely that death was caused by self-poisoning. Human & Experimental Toxicology (2007) 26, 667-670.
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Affiliation(s)
- Cláudia Margalho
- Instituto Nacional de Medicina Legal, Delegação de Coimbra, Largo da Sé Nova, 3000-213 Coimbra, Portugal.
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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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Darcy P, Dredge K, Kellehir P, Kelly JP, Leonard BE, Chambers PL. Acute toxicity profile of maprotiline in the rat. PHARMACOLOGY & TOXICOLOGY 1999; 85:276-81. [PMID: 10628903 DOI: 10.1111/j.1600-0773.1999.tb02022.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of the present study was to examine the toxic effects of single oral administrations of the antidepressant maprotiline at 150 mg/kg or 300 mg/kg using female Sprague-Dawley rats. Body-weight gain was significantly reduced in the group receiving 300 mg/kg on days 1-5 of the study (P<0.01). A significant reduction in food and water intake was observed on days 1 and 2 of the study (P<0.01) in the 300 mg/kg group and on day 1 in the 150 mg/kg group (P<0.05). There was a significant decrease in nocturnal home cage activity over the first five days of the study in the 300 mg/kg group (P<0.01). A significant hypothermic response was observed in both 150 and 300 mg/kg groups at 1, 2 and 4 hr after dosing (P<0.01), that had returned to control values within 8 hr following administration. This study demonstrates that a multi-parameter approach is appropriate for the investigation of high doses of antidepressants in rodents.
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Affiliation(s)
- P Darcy
- Department of Pharmacology, National University of Ireland, Galway.
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12
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Postmortem Amitriptyline Pharmacokinetics in Pigs after Oral and Intravenous Routes of Administration. J Forensic Sci 1998. [DOI: 10.1520/jfs16151j] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hilberg T, Mørland J, Bjørneboe A. Postmortem release of amitriptyline from the lungs; a mechanism of postmortem drug redistribution. Forensic Sci Int 1994; 64:47-55. [PMID: 8157229 DOI: 10.1016/0379-0738(94)90241-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
An experimental rat model was used to study postmortem redistribution of amitriptyline (AMI). Two hours after a subcutaneous injection with 20 mg of amitriptyline, the rats (n = 40) were anaesthetized and blood samples were drawn from the femoral vein and the heart. The rats were then sacrificed by CO2 and left at room temperature for either 0.1, 1, 2, 5, 24, 48, or 96 h. Postmortem blood samples from the heart and the inferior vena cava, and tissue samples from the lungs, heart, liver, right kidney, thigh muscle, the wall of the abdominal vena cava and brain were analyzed by high performance liquid chromatography. A significant increase was observed within 2 h postmortem in heart blood and later also in blood from the inferior vena cava. At 96 h postmortem the concentration increase was 4.4 +/- 0.5-fold (P < 0.01) and 3.0 +/- 1.1-fold (P < 0.05) as compared to the antemortem values observed in heart blood and blood from the inferior vena cava, respectively (mean +/- SEM). In the lungs there was a fall in the concentration of AMI from 148 +/- 16.7 mumol/kg at 0.1 h to 49.1 +/- 7.8 mumol/kg at 96 h postmortem (P < 0.01). In the vessel wall of the abdominal vena cava there was also a significant fall in drug concentration, while in heart muscle and liver an increase in drug concentration was observed. In animals where the lungs were removed agonally (n = 7), the drug concentration in heart blood had increased significantly less at 2 h postmortem.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- T Hilberg
- National Institute of Forensic Toxicology, Oslo, Norway
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