Prediction of steady-state verapamil plasma concentrations in children and adults.

With data on adults from two previous articles it was found that the average steady-state plasma concentration of verapamil in subjects on long-term oral therapy of 80 mg every 6 hr (Y) correlated strongly with the area under the curve from zero to infinity (AUC0-x/6 (X) where the area refers to that for a single oral dose of 80 mg (Y - 2.41X, n - 15, r - 0.923, P less than 0.001). Steady-state concentrations are predictable from the single-dose data, with an average absolute deviation of 11.1%. We gave seven children (7 to 19 yr old) an initial intravenous bolus dose of 0.1 mg/kg, followed by a 20-min constant rate infusion of 0.007 mg/kg/min. Twenty-four hours after the bolus dose they were put on oral therapy (40 to 80 mg every 6 hr) and 1 mo later the minimum steady-state verapamil plasma concentration (Cminss) was measured. Plasma concentration-time data obtained after the infusion were fitted to biexponential (two sets) or triexponential equations (five sets). The coefficients of the postinfusion polyexponential equations were converted to those for the 0.1-mg/kg bolus dose alone. Mean parameters estimated were: plasma clearance 0.500 l/min, steady-state volume of distribution 279 l, V beta 394 l, half-life 9.17 hr, and mean residence time 10.0 hr. Many correlations were made between the oral Cminss values and functions obtained from the intravenous data. The best correlation was that between Cminss and the predicted steady-state concentration at 3 hr after dosing when bolus doses would be given at 6-hr intervals based on the single-dose intravenous date (r = 0.985, P less than 0.001); this correlation allowed Cminss to be predicted with an average absolute deviation of 10%. Norverapamil was measured in plasma after oral dosing, but was not detectable after intravenous dosing.

A modified sensitive spectrofluorometric method for the determination of propranolol in serum.

A modification of the spectrofluorometric propranolol procedure of Shand and associates and Ambler and colleagues is presented. A 3-ml volume of propranolol in serum is made basic with sodium hydroxide and extracted with 1.5% isoamyl alcohol in n-heptane. The drug is back-extracted into a mixture of 0.01 M citric acid in 50% ethylene glycol and measured spectrofluorometrically with the use of 299 nm for excitation and 352 nm for emission. Excellent linearity is observed in the 25--200 ng/ml range. The effects of sodium hydroxide, citric acid, and ethylene glycol concentration on the procedure were investigated. Ethylene glycol--citric acid in water is a better back-extracting mixture from the organic phase than hydrochloric acid. Using pentyl acetate as the extracting solvent instead of isoamyl alcohol in n-heptane did not change significantly the amount of the drug extracted. Other extracting solvents investigated did not increase sensitivity. At high citric acid concentrations a decrease in fluorescence intensity was observed at 350 nm. Interferences from other drugs using this procedure were investigated. Quinidine, methaqualone, and procainamide interfere at therapeutic levels.

Gas-chromatographic determination of mexiletine with a nitrogen-selective detector.

The authors present a procedure for the determination of mexiletine in serum. The drugs are extracted under basic conditions into n-heptane/isobutanol (96/4 by vol) and then extracted again into 1 mol/L H2SO4. The acidic solution is made basic with sodium hydroxide, reextracted with diethyl ether, and the extract evaporated. The residue is redissolved in ethanol and analyzed by gas chromatography with a nitrogen-selective detector. By use of two internal standards, diphenhydramine and p- chlorodisopyramide , concentration and instrument response are related linearly from 500 micrograms/L to 4.0 mg/L. Interferences from other drugs also are eliminated by using two internal standards. Within-run precision (CV) was 5% at the 1 and 2 mg/L concentration: between-run precision was 10% and 5% at those respective concentrations. Interference studies indicate that most commonly prescribed basic drugs will not interfere with this procedure.

Identification of misused drugs in the clinical laboratory. I. Tricyclics.

A systematic approach evaluating the abuse of tricyclic drugs in the hospital emergency room from the laboratory point of view is presented. This comprehensive screen involves qualitative colorimetric tests, ultraviolet (UV) spectrophotometry, thin layer chromatography (TLC), gas chromatography (GC) and gas chromatography-mass spectrometry (GC/MS). Laboratories with varying facilities and resources can adapt the present screen. Amitriptyline, doxepin, loxapine and desipramine misuse were identified and confirmed using the proposed methodology in 14 cases. Increasing misuse of tricyclic antidepressants requires that the clinical laboratory have a systematic approach to identify and confirm the presence of these drugs in emergency room patients.

A modified ultraviolet spectrophotometric method for the determination of theophylline in serum in the presence of barbiturates.

Ultraviolet spectrophotometry is the most commonly used technique for the determination of theophylline levels for therapeutic monitoring. Common interferences in most methods are barbiturates and xanthines. A modified method which eliminates interferences from barbiturates and most xanthines is presented. Theophylline is extracted from serum with chloroform/isopropanol at pH 7.4 back extracted into dilute hydrochloric acid and then the solution is made alkaline with sodium hydroxide. Barbiturate interferences are eliminated. Interference from caffeine, uric acid, 7-(2,3-dihydroxypropyl)theophylline, xanthine, and hypoxanthine are not observed. Theobromine, and the metabolite 3-methylxanthine interfere. Interference is not observed from quinidine, diazepam, salicylate, glutethimide, methylprylon, propranolol, methaqualone, dilatin and ethchlorvynol. Sulfanilamide, procainamide and chlordiazepoxide interfere.

A systematic laboratory approach for the identification of drugs in presumably poisoned (overdosed) patients.

A systematic approach for evaluating the abuse of drugs in patients presenting to the hospital emergency room is presented from the laboratory point of view. This comprehensive screen involves qualitative colorimetric tests, ultraviolet (UV) spectrophotometry, thin layer chromatography (TLC), gas chromatography (GC), and gas chromatography - mass spectrometry (GC-MS). Laboratories with varying resources can adopt the screen presented. Thirty-two cases were evaluated with the methodology; these included tricyclic antidepressants, benzodiazepines, phencyclidine, methaqualone, and barbiturates. Increasing misuse of drugs requires that the clinical laboratory have a systematic approach to identify and confirm the presence of these drugs in emergency room patients.

Reaction of alkaline sodium picrate with creatinine: I. Kinetics and mechanism of formation of the mono-creatinine picric acid complex.

Spectrophotometric, kinetic, and nuclear magnetic resonance studies indicate that alkaline sodium picrate and creatinine react to form a 1/1 aduct between picric and creatinine, with a stability constant of log K= 4.26. Kinetic studies indicate that the forward reaction is first order with respect to picric acid, hydroxide, and creatinine concentration. The reverse reaction, the dissociation of the 1/1 complex, shows a complex dependence on hydroxide concentration. The expression for the observed pseudo-first-order rate constant in the presence of excess picric acid is: Kobsd = K1K0[P][OH] +[K2[OH]x. A value of K1K0 = 5.0 (mol/liter)-2s-1 is obtained. For accurate analytical results with this reaction, hydroxide concentration must be maintained at a constant value for both samples and standards.

Determination of quinidine in serum by spectrofluorometry, liquid chromatography and fluorescence scanning thin-layer chromatography.

Quinidine is determined in serum by direct and extraction spectrofluorometry, by reflectance fluorescence scanning thin-layer chromatography (TLC), and by high-performance liquid chromatography (HPLC). Least-squares analyses of patients' sera (n = 62) analyzed first by direct fluorometry (x) and then HPLC (y) gave a slope of 0.52, an y-intercept of -0.40, a standard error of estimate of 0.65, and a correlation coefficient of 0.83. Comparison of patients' sera (n = 59) determined by extraction fluorometry (x) and then HPLC (y) gave a slope of 0.998, an y-intercept of -0.175, a standard error of estimate of 0.30, and a correlation coefficient of 0.96. Comparison of patients' sera (n = 36) by HPLC (x) and then reflectance fluorescence scanning TLC (y) gave a slope of 0.837, an y-intercept of 0.152, and a correlation coefficient of 0.94. Methaqualone and oxazepam interfere with HPLC. Within-run precision is 1.6, 1.0, 5.2 and 3.0% by direct fluorometry, extraction fluorometry, TLC and HPLC while between-run precision is 5, 3.5, 9 and 6.0%, respectively.

Midazolam determination by gas chromatography, liquid chromatography and gas chromatography--mass spectrometry.

Midazolam is determined in serum by gas chromatography with a nitrogen-selective detector, by liquid chromatography, and by gas chromatography--mass spectrometry. Comparable results are obtained with the three techniques with a within-run precision of 9% by gas chromatography and gas chromatography---mass spectrometry and 5% by liquid chromatography. Between-run precision is 13% by gas chromatography--mass spectrometry and 10% by liquid chromatography. Comparison of patient's sera by gas chromatography (x), liquid chromatography (y), and by gas chromatography (x), gas chromatography--mass spectrometry (y) gave correlations of 0.98 and 0.89, respectively. Interferences observed when using one technique, for example liquid chromatography, can be eliminated by analyzing the sample extract with one of the other techniques.

Disopyramide determination by gas chromatography, liquid chromatography, and gas chromatography--mass spectrometry.

Disopyramide is determined in serum by gas chromatography with a nitrogen-selective detector, by liquid chromatography, and by gas chromatography--mass spectrometry. Comparable results are obtained with the three techniques, with a within-run and between-run precision of 5 to 10% (coefficient of variation). Least-squares analysis of data on patients' sera, analyzed first by gas chromatography (y) and then liquid chromatography (x), gave a slope of 1.12; y-intercept, -0.31; standard error of estimate, 0.46; and correlation coefficient, 0.94. Comparison of patients' sera by gas chromatography (y) and then by gas chromatography--mass spectrometry (x) gave a slope of 0.94; y-intercept, 0.42; standard error of estimate, 0.38; and correlation coefficient, 0.97. Interferences observed when using one technique--for example, gas chromatography--can be eliminated by analyzing the sample extract with one of the other techniques.

Gas-chromatographic determination of disopyramide in serum, with use of a nitrogen-selective detector.

In this procedure for disopyramide in serum, the drug is extracted into n-heptane/isobutanol (96/4 by vol), then back-extracted into 1 mol/L H2SO4. The acidic solution is made basic with sodium hydroxide, extracted with diethyl ether, and the extract evaporated. The residue is redissolved in ethanol and analyzed by gas-chromatography, with use of a nitrogen-selective detector. p-Chlorodisopyramide is used as internal standard. Concentration and instrument response for serum extracts are linearly related from 1 to 5 mg/L, the slope being 0.61, the y-intercept -0.10, the standard error of estimate 0.01, and the correlation coefficient 0.99. Within-run precision was 6 and 4% for 3 and 5 mg/L concentrations, respectively, with a between-run precision of 7% at the 3 mg/L concentration. Diazepam interferes, but procainamide, chlordiazepoxide, quinidine, lidocaine, propranolol, sulfanilamide, and many other basic drugs do not.

Determination of therapeutic and toxic concentrations of doxepin and loxapine using gas-liquid chromatography with a nitrogen-sensitive detector, and gas chromatography-mass spectrometry of loxapine.

A gas-liquid chromatographic procedure is presented for the determination of therapeutic and toxic serum levels of doxepin and loxapine, using a nitrogen-phosphorus-sensitive detector. Amitriptyline is used as the internal standard. The method is accurate, sensitive and specific with no derivatization required prior to analysis. An advantage of the procedure is the small serum sample size needed for analysis and the selectivity and sensitivity of the detector, with the limit of detection being 3 and 2 microgram/l for doxepin and loxapine, respectively. Nine cases of doxenin and loxapine misuse are presented. Serum doxepin concentrations ranged from 113 to 439 microgram/l, with a loxapine concentration of 192 microgram/l observed in one patient. The presence of the tricyclics was identified and confirmed by gas chromatography-mass spectrometry and the mass spectrum of loxapine is reported.

Pitfalls of the alcohol dehydrogenase procedure for the emergency assay of alcohol: a case study of isopropanol overdose.

We describe a case of ethanol and isopropanol ingestion that resulted in coma. The concentration of ethanol and isopropanol was 0.90 and 1.65 g/liter in serum and 3.12 and 5.34 g/liter in gastric contents. With an enzymatic (alcohol dehydrogenase) method for ethanol determination we obtained erroneous analytical results. Because of partial cross reactivity with isopropanol, ethanol concentration was overestimated and total alcohol (i.e., the contribution of isopropanol) was underestimated. This was recognized by measuring serum osmolality. Differences between measured and calculated serum osmolality that are not accounted for by the serum ethanol concentration as determined by an enzymatic ethanol method must be further investigated by specific methods to see if other alcohols are present.

Hemodynamic effects of verapamil in children and adolescents with hypertrophic cardiomyopathy.

The acute hemodynamic effects of verapamil were evaluated in nine children with hypertrophic cardiomyopathy. Verapamil, 0.1 mg/kg, was administered as an i.v. bolus over 2 minutes, followed by a 20-minute continuous infusion of 0.007 mg/kg/min. Hemodynamic measurements were obtained at rest in nine patients and at maximal supine bicycle exercise in seven before and 15 minutes after verapamil. At rest, verapamil increased the mean cardiac output from 3.3 +/- 0.9 to 3.7 +/- 0.9 l/min/m2 (+/- SD) (p less than 0.02) and decreased left ventricular end-diastolic pressure from 19.3 +/- 8.1 to 14.5 +/- 6.9 mm Hg (p less than 0.006). In six patients with resting left ventricular outflow tract obstruction, the systolic pressure gradient decreased from 17.5 +/- 7.2 to 5.2 +/- 4.5 mm Hg (p less than 0.04). Repeat supine bicycle exercise testing after verapamil showed increases in total work performed (1743 +/- 1284 to 3168 +/- 1643 kg-m, p less than 0.006) and maximal cardiac index during exercise (6.5 +/- 1.3 to 7.8 +/- 1.8 l/min/m2, p less than 0.05), and decreases in maximal exercise left ventricular end-diastolic pressure (29.1 +/- 10.1 to 19.3 +/- 10.4 mm Hg, p less than 0.002) and left ventricular systolic outflow tract gradient (31.2 +/- 10.5 to 1.75 +/- 1.7 mm Hg, p less than 0.04). These results suggest that verapamil may be an effective therapeutic agent for the treatment of hypertrophic cardiomyopathy in children.

Gas-chromatographic determination of verapamil and norverapamil, with a nitrogen-selective detector.

We present a procedure for the determination of verapamil and its metabolite, norverapamil, in serum. The drugs are extracted under basic conditions into n-heptane/2-butanol (96/4 by vol) and then extracted again into 1 mol/L H2SO4. The acidic solution is made basic with sodium hydroxide, re-extracted with diethyl ether, and the extract evaporated. The residue is redissolved in ethanol and analyzed by gas chromatography with a nitrogen-selective detector. By use of two internal standards, prazepam and D-517 (a verapamil analog), concentration and instrument response are linearly related from 50 micrograms/L to 5 mg/L. Within-run precision (CV) was 3 and 5% for both verapamil and norverapamil at concentrations of 100 and 250 micrograms/L; between-run precision was 11 and 9% at those respective concentrations. Interference studies indicate that most commonly prescribed basic drugs will not interfere with this procedure.