A practical approach for measurement of antihypertensive medication adherence in patients with resistant hypertension.

Confirmation of medication adherence is a challenge in clinical practice and essential for the accurate diagnosis of resistant hypertension. Although it is well established that drug adherence is critical for controlling blood pressure, there are still difficulties applying a simple, inexpensive, and reliable assessment of adherence in the clinical setting. We aimed to test a simple method to assess adherence in resistant hypertensive (RH) patients. A pilot study with normotensives or mild/moderate hypertensive subjects was performed to provide a fluorescence cutoff point for adherence. After that, 21 patients referred to the Resistant Hypertension Clinic had triamterene prescribed and were monitored for a 30-day period. We conducted two unannounced randomly selected home visits for urine collection to test drug intake that day. Office, home and 24-hour ambulatory blood pressure, biochemical data, and the 8-item Morisky Medication Adherence Scale (MMAS-8) were systematically acquired. According to adherence indicated by urine fluorescence, subjects were divided into adherent and nonadherent groups. We found 57% of nonadherence. No differences were found between groups regarding baseline characteristics or prescribed medications; Kappa's test showed concordance between adherence through MMAS-8 items and fluorescence (kappa = 0.61; 95% confidence interval: 0.28-0.94; P = .005). Nonadherent patients had higher office (81 ± 11 vs. 73 ± 6 mm Hg, P = .03), 24-hour ambulatory blood pressure monitoring (75 ± 9 vs. 66 ± 7 mm Hg, P = .01), and home blood pressure measurement (77 ± 9 vs. 67 ± 8 mm Hg, P = .01) diastolic blood pressure than their counterparts. Nonadherence to antihypertensive therapy is high in patients with RH, even when assessed in clinics specialized in this condition. Fluorometry to detect a drug in the urine of RH patients is safe, easy, and reliable method to assess adherence.

Two-phase and three-phase liquid-phase microextraction of hydrochlorothiazide and triamterene in urine samples.

This paper reports the applicability of two-phase and three-phase hollow fiber based liquid-phase microextraction (HF-LPME) for the extraction of hydrochlorothiazide (HYD) and triamterene (TRM) from human urine. The HYD in two-phase HF-LPME is extracted from 24 mL of the aqueous sample into an organic phase with microliter volume located inside the pores and lumen of a polypropylene hollow fiber as acceptor phase, but the TRM in three-phase HF-LPME is extracted from aqueous donor phase to organic phase and then back-extracted to the aqueous acceptor phase, which can be directly injected into HPLC for analysis. Under optimized conditions preconcentration factors of HYD and TRM were obtained as 128 and 239, respectively. The calibration curves were linear (R(2) ≥ 0.995) in the concentration range of 1.0-100 µg/L for HYD and 2.0-100 µg/L for TRM. The limits of detection for HYD and TRM were 0.5 µg/L. The intra-day and inter-day RSD based on four replicates were obtained as ≤5.8 and ≤9.3%, respectively. The methods were successfully applied for determining the concentration of the drugs in urine samples. Copyright © 2015 John Wiley & Sons, Ltd.

Synthesis of monodisperse molecularly imprinted microspheres with multi-recognition ability via precipitation polymerization for the selective extraction of cyromazine, melamine, triamterene and trimethoprim.

Through precipitation polymerization, three monodisperse molecularly imprinted polymers (MIPs) containing imprints of 2,4-diamino-6-methyl-1,3,5-triazine (DM), cyromazine (CY) or trimethoprim (TM), were synthesized using methacrylic acid as functional monomer, divinylbenzene as cross-linker, and a mixture of acetonitrile-toluene (90/10, v/v) as porogen. The morphology and selectivity of the MIPs were characterized and compared systematically. The MIPs had the best specific binding in pure acetonitrile, and the data of adsorption experiment were fitted well with Langmuir and Freundlich model. In addition, DM-MIPs showed the excellent binding and multi-recognition capability for CY, melamine (ME), triamterene (TA) and TM, and the binding capacity were 7.18, 7.56, 5.66 and 5.45µmol/g, respectively. Due to the pseudo template and the ability of multi-recognition, DM-MIPs as sorbent material could avoid the effect of template leakage on quantitative analysis. Therefore, DM-MIPs were used as a solid-phase extraction material to enrich ME, CY, TA and TM from different bio-matrix samples for high performance liquid chromatography analysis. Under the optimized conditions, the recoveries of three spiked levels in different bio-matrix samples were ranged from 80.9% to 91.5% with RSD≤4.2 (n=3).

[Simultaneous determination of four drugs for kidney diseases in urine by high performance liquid chromatography].

A high performance liquid chromatographic (HPLC) method was proposed for the simultaneous determination of four drugs for kidney disease, enalapril, triamterene, furosemide and valsartan. After proteins being removed by acetone precipitation method, freeze drying and redissolving in mobile phase, the urine samples were analyzed by HPLC. Chromatographic separation was performed on a WondaSil C18-WR (150 mm x 4.6 mm, 5 µm) in gradient elution mode using 10.0 mmol/L ammonium acetate aqueous solution (pH 3.90) and acetonitrile as mobile phases at a flow rate of 1.0 mL/min. The detection wavelength was set at 254 nm. Under the optimized conditions, good linearities were obtained in the range of 0.15-300 mg/L, 0.05-100 mg/L, 0.75-750 mg/L, 0.05-100 mg/L, and the detection limits were 1.38 x 10(-2), 7. 67x103, 3.69x 10-2, 1. 16x 10-2 mg/L for enalapril, triamterene, furosemide and valsartan, respectively. The recoveries were in the range of 89.49%-99.20% with the relative standard deviations (RSDs) among 4.12%-9.44%. The method is simple, accurate and effective, and the results showed the method is applicable for the analysis of the four drugs for kidney diseases in real urine samples.

Selective recognition of Triamterene in biological samples by molecularly imprinted monolithic column with a pseudo template employed.

Melamine (MAM) was employed as a pseudo template to prepare a molecularly imprinted polymer monolithic column which presents the ability of selective recognition to Triamterene (TAT), whose structure was similar to that of MAM. Methacrylic acid and ethylene glycol dimethacrylate were applied as functional monomer and cross-linker, respectively, during the in situ polymerization process. Chromatographic behaviors were evaluated, the results indicated that the molecularly imprinted polymer monolithic column possessed excellent affinity and selectivity for TAT, and the imprinting factor was high up to 3.99 when 7:3 of ACN/water v/v was used as mobile phase. In addition, the dissociation constant and the binding sites were also determined by frontal chromatography as 134.31 µmol/L and 132.28 µmol/g, respectively, which demonstrated that the obtained molecularly imprinted polymer monolith had a high binding capacity and strong affinity ability to TAT. Furthermore, biological samples could be directly injected into the column and TAT was enriched with the optimized mobile phase. These assays gave recovery values higher than 91.60% with RSD values that were always less than 3.5%. The molecularly imprinted monolithic column greatly simplified experiment procedure and can be applied to preconcentration, purification, and analysis of TAT in biological samples.

Bioavailability study of triamterene and xipamide using urinary pharmacokinetic data following single oral dose of each drug or their combination.

An efficient chromatographic method for the simultaneous determination of triamterene (TRI) and xipamide (XIP) in urine samples, based on high performance liquid chromatography with photodiode array detector (HPLC-DAD) has been developed. The HPLC separation was performed on a RP stainless-steel C-18 analytical column (250 mm × 4.6 mm, 5 µm) with a gradient elution system of 0.05 M phosphate buffer adjusted to pH 4.0 and methanol as the mobile phase. The method was used to determine the urinary excretion profile and to calculate different urinary pharmacokinetic parameters following oral dose of their combination compared with single oral doses of each drug and hence comparing their bioavailability. Quantitation was performed using chlorthalidone as internal standard. The calibration graphs of each drug were rectilinear in the range of 0.2-40 µg/mL urine for TRI and 0.2-15 µg/mL urine for XIP. An HPLC-DAD method was also successfully developed for the simultaneous determination of the investigated drugs in pharmaceutical preparations. The methods were validated in terms of linearity, accuracy, precision, selectivity, limits of detection and quantitation and other aspects of analytical validation.

Determination of losartan and triamterene in pharmaceutical compounds and urine using cathodic adsorptive stripping voltammetry.

A square-wave voltammetric procedure for the electroanalytical determination of losartan and triamterene in Britton-Robinson buffer (pH 3.0, 0.1 mol L(-1)) as a supporting electrolyte containing 30 ng mL(-1) of copper ions was developed. Opposite to the case of triamterene, losartan can not be reduced at a mercury electrode alone, but a new peak appears at -0.25 V in the presence of copper due to the formation of a complex between copper(II) and losartan. An accumulation potential of -0.30 V during 80 s for the prior adsorption of losartan-copper(II) and triamterene on the electrode surface was used. The response of the system was found to be linear in the range of 30.0 - 270.0 nmol L(-1) for losartan and two linear dynamic ranges containing 0.5-200.0 and 200.0-400.0 nmol L(-1) of triamterene. The limits of detections were 9.7 and 0.3 nmol L(-1) for losartan and triamterene, respectively. The relative standard deviations for five replicate analyses of 100.0 and 10.0 nmol L(-1) losartan and triamterene were 5.5%. Applicability to assay the drugs in urine and pharmaceutical formulations was illustrated with satisfactory results. The direct-current polarography of triamterene indicates that the reduction of a related drug is strongly dependent on the pH of the solution. A linear segment was found with slope value of -63.6 mV pH(-1) in the pH range of 2.0 - 6.0. The stoichiometry and complex formation constant (beta) for losartan-Cu(II), number of transfer electrons (n), transfer coefficients (alpha) and number of proton transfers were also estimated.

Determination of diuretics in human urine by hollow fiber-based liquid-liquid-liquid microextraction coupled to high performance liquid chromatography.

In competition sports, a diuretic is a substance widely prohibited by the World Anti-Doping Agency (WADA). In this paper, a sensitive, rapid and convenient analytical method for the determination of acidic [furosemide (FUROS) and bumetanide (BUMET)] and basic [triamterene (TRIAM)] diuretics in human urine was developed by hollow fiber-based liquid-liquid-liquid microextraction (LLLME) coupled with HPLC-UV. The LLLME conditions, such as the organic extraction solvent, the acidity and basicity of the donor- and acceptor-phases, stirring speed, extraction time and ionic strength, were studied in detail. Under the optimum conditions, the linear ranges of furosemide, bumetanide and triamterene were 1.2-250, 5.0-250 and 5.0-500 ng mL(-1), respectively. The detection limits were 0.5 ng mL(-1) for furosemide, 1.2 ng mL(-1) for bumetanide and 2.0 ng mL(-1) for triamterene. The LLLME obtained a great improvement of the detection limits for all the analytes considered here, to the ng mL(-1) level, which almost reaches the level of the LC-MS method. This new LLLME method provided very high enrichments: 117-fold for furosemide, 175-fold for bumetanide and 68-fold for triamterene. Since the hollow fiber membrane was sealed, it could be used for extracting the diuretics directly from 'dirty' human urine samples without any clean-up procedures. With LLLME-HPLC, the corresponding recoveries ranged from 79.2 to 109% with the RSDs not exceeding 5.5% for the three diuretics in the spiked urine samples. The method was successfully applied to analyse the amounts of the three diuretics in real urine samples of volunteers after oral drug-taking. This new method proves to be sensitive and reliable and thus renders a very suitable means for the determination of trace diuretics in human urine based on the common HPLC instrument.

Fast quantitative determination of diuretic drugs in tablets and human urine by microchip electrophoresis with native fluorescence detection.

Microchip electrophoresis (MCE) with native fluorescence detection has been applied for the fast quantitative analysis of pharmaceutical formulations. For this purpose, methods for fast separation and sensitive detection of the unlabeled diuretic drugs, amiloride, triamterene, bendroflumethiazide (BFMTZ), and bumetanide were developed. An epifluorescence setup was used enabling the coupling of different lasers into a commercial fluorescence microscope. The detection sensitivity of different excitation light sources was compared utilizing either a HeCd laser (lambda(exc) = 325 nm), a frequency quadrupled Nd:YAG laser (lambda(exc) = 266 nm), or a mercury lamp (lambda(exc) = 330-380 nm). At optimal conditions using the HeCd laser, the drugs were separated within 15 s with LODs less than 1 mug/mL for the four compounds. A linear relationship between concentration and peak area was obtained in the concentration range of 0.05-20 microg/mL with a mean correlation coefficient of around 0.996 for all analytes. The method was successfully applied to the analysis of the respective drugs in commercial formulations and in human urine without interference from other constituents. These data show that MCE has a great potential for reliable drug analysis.

Multicommuted flow-through fluorescence optosensor for determination of furosemide and triamterene.

Multicommutation implemented with flow-through optosensors is a very promising area of research. This recent approach benefits from the advantages of both methods and results in high sensitivity, selectivity, and speed, and little waste generation. This paper reports the simultaneous determination of furosemide and triamterene, two widely used diuretics, by measurement of their native fluorescence. The system has been proved to be useful for determination of both analytes in pharmaceutical preparations and for determination of triamterene in human urine and serum. A minicolumn filled with Sephadex SPC-25 microbeads was used to achieve separation of both analytes before detection in a flow-through cell filled with the same resin. The sensor is linear in the range 50-1200 and 0.4-8 ng mL(-1) with detection limits of 15 and 0.1 ng mL(-1) for furosemide and triamterene, respectively.

Capillary electrophoretic determination of triamterene, methotrexate, and creatinine in human urine.

A capillary zone electrophoresis (CZE) method using a fused-silica capillary (60.2 cm x 75 microm ID) was investigated for the determination of triamterene (TRI), methotrexate (MTX), and creatinine (CREA) in human urine. The separation was performed using a hydrodynamic injection time of 7 s (0.5 psi), a voltage of 25 kV, a capillary temperature of 30 degrees C, and 40 mM phosphoric acid adjusted to pH 2.25 by addition of triethanolamine as separation electrolyte. Under these conditions, analysis takes about 15 min. A linear response over the 0.5-15.0 mg L(-1) concentration range was found for TRI and MTX, and 0.5-80.0 mg L(-1) for CREA. Dilution of the sample (water:urine, 1:1 for TRI and MTX, and 1:25 for CREA determination) was the only step necessary prior to analysis by electrophoresis. The developed method is easy, rapid, and sensitive and has been applied to determine triamterene,methotrexate, and creatinine in urine samples with satisfactory results.

Determination of triamterene and its main metabolite hydroxytriamterene sulfate in human urine by capillary electrophoresis using ultraviolet absorbance and laser-induced fluorescence detection.

Two capillary electrophoresis methods have been developed for the direct determination of triamterene and its main metabolite hydroxytriamterene sulfate in human urine. Analytes were detected using conventional UV detection as well as laser-induced fluorescence (LIF) detection with an HeCd-laser operating at a wavelength of 325 nm. The results of both detection techniques were compared. Indeed, the limit of quantification was eightfold lower using LIF detection (50 ng/ml) in comparison to UV detection (400 ng/ml). As no interference due to endogenous urine compounds was observed, direct urine analysis was feasible. Analysis was very simple and fast-one run could be performed within less than 10 min (CE-UV method) and 2.5 min (CE-LIF method), respectively. Both assays were fully validated and applied to urine samples from a human volunteer. The results of the application of the CE-LIF method to human urine samples are presented in this publication.

Determination of triamterene and leucovorin in biological fluids by UV derivative-spectrophotometry and partial least-squares (PLS-1) calibration.

The resolution of binary mixtures of triamterene (TAT) and leucovorin (LV) by application of first-derivative spectrophotometry and by application of Partial Least Squares calibration (PLS-1) was performed. Triamterene is determined in presence of leucovorin directly in the absorption spectra at 358 nm, and leucovorin is determined in the first-derivative spectra at 305.6 nm, zero-crossing of the triamterene. The mean recovery values in urine samples were 102 and 97% for TAT and LV, respectively. Partial Least Squares calibration (PLS-1) multivariate calibration of spectrophotometric data, have been applied to the determination of these compounds in serum and in urine without pretreatment of the samples. The absorption spectra of samples of serum or urine, spiked with triamterene and/or leucovorin, were used to perform the optimization of the calibration matrices by PLS-1 method. Mean recovery values were of 107 and 108% for TAT and LV in serum samples, and 98 and 91% for TAT and LV in urine samples.

Simultaneous direct determination of amiloride and triamterene in urine using isopotential fluorometry.

A method for the simultaneous fluorometric determination of two diuretics in urine is proposed. The combination of matrix isopotential synchronous fluorescence (MISF) and first derivative techniques provides good analytical results. MISF spectra are obtained by calculating the isopotential trajectory in the three-dimensional fluorescence spectrum for a urine solution. In the spectral contour, the trajectory is taken to be the portion of the line that passes by the fluorescence maxima of both diuretics (lambda(ex) = 365 and lambda(em) = 413 nm for amiloride and lambda(ex) = 365 and lambda(em) = 437 nm for triamterene). Because contour lines connect points of identical intensity and the trajectory is part of a contour line, it is called "isopotential." Analyses was carried out in a 1/1 (v/v) ethanol/water mixture, using an apparent pH of 6.3 provided by 0.01 M sodium/citrate citric acid buffer. Urine samples are diluted 50 times and provide linear calibration plots at amiloride and triamterene concentrations up to 320 and 100 ng mL(-1), respectively. The goodness of the analytical signal was checked by using variance analysis. Signals recorded throughout the calibration range were subjected to three calibrations per each analyte, both in the absence and in the presence of variable amounts of the other analyte. Differences between individual calibrations and slopes were compared with those within individual calibrations. Based on the results, triamterene and amiloride can be accurately quantified in the presence of each other. The limit of detection calculated according to Clayton who uses error propagation throughout the calibration curve and a noncentralized security factor was 16.8 and 2.4 ng mL(-1) for amiloride and triamterene, respectively.

The effect of diflunisal on the elimination of triamterene in human volunteers.

A major metabolic pathway for triamterene (a potassium sparing diuretic) is aromatic hydroxylation followed by sulphate conjugation. Diflunisal (a salicylate anti-inflammatory agent) also undergoes sulphate conjugation of its phenolic group as a major pathway. We investigated the possible effect of diflunisal on the elimination of triamterene (competition for phenolic sulphonation) in six healthy volunteers by studying the disposition of single doses of triamterene (100 mg) taken alone and in the presence of steady-state levels of diflunisal. Diflunisal coadministration (500 mg b.i.d.) had no effect on the pharmacokinetics of triamterene itself. However, plasma AUC of p-hydroxytriamterene sulphate was greater (4.6 times), and its renal clearance lower (0.24 times), in the presence of diflunisal. There was no change in the formation clearance or protein binding of p-hydroxytriamterene sulphate in the presence of diflunisal. The data point to competition for renal excretory pathways rather than sulphonation capacity. This interaction could have clinical relevance since p-hydroxytriamterene sulphate is pharmacologically active.

Pharmacokinetics and pharmacodynamics of triamterene and hydrochlorothiazide and their combination in healthy volunteers.

Although triamterene has been in clinical use for over 30 years, the linearity of triamterene kinetics was not systematically tested. Moreover, although triamterene is mostly applied concomitantly with thiazide-type diuretics the interaction of triamterene (TA) with hydrochlorothiazide (HCT) is subject to a controversial discussion. Therefore, the aim of this study was to examine the dose linearity of TA and the pharmacokinetic and pharmacodynamic interaction of triamterene and hydrochlorothiazide. In the first study 10 healthy volunteers received 0, 12.5, 25, 50, and 100 mg triamterene orally in a balanced crossover design. In the second study 0, 25, and 50 mg TA with 12.5, and 25 mg HCT, respectively, were administered to 12 healthy volunteers. Urine volume and concentration of sodium, TA, hydroxytriamterene sulfate (OH-TA ester), and HCT were measured by flame photometry and thin-layer chromatography, respectively. The observation period for each treatment was 3 days and the drug was given on the second day. Sodium excretion was increased by both drugs. Renal excretion of both TA and OH-TA ester seemed to be reduced at higher doses. However, statistical evaluation revealed no significant (p = 0.37, and p = 0.20, respectively) deviation from linearity. Renal excretion of HCT was not affected by TA and vice versa. However, renal excretion of OH-TA ester is significantly reduced when HCT is administered concomitantly. The renal excretion rate of sodium can be described by a common Emax model when the effects of the excretion rates of both TA and HCT are additive. It is concluded that the pharmacokinetics of TA is linear within the tested dose range and that pharmacodynamic additivity of HCT and TA is not due to a pharmacokinetic interaction. The results support the hypothesis of a sequential nephron blockade for both drugs acting on different tubular segments.

Direct determination of diuretic drugs in urine by capillary zone electrophoresis using fluorescence detection.

Four diuretic drugs banned in sport (amiloride, triamterene, bendroflumethiazide and bumetanide) have been separated by capillary zone electrophoresis (CZE) and detected using conventional fluorescence spectrometry. The effect of pH on electrophoretic parameters such as migration time, peak efficiency and peak height is discussed. Complete separation of the four drugs is achieved in less than 8 min at pH 8. No interference due to endogenous urine components is observed and thus direct urine analysis is feasible. Analytical figures of merit including precision and limits of detection are presented. Limits of detection range between 0.5 fmol for triamterene and 21.6 fmol for bumetanide.

The identification and quantitation of triamterene in blood and urine from a fatal aircraft accident victim.

Triamterene, a diuretic drug used in combination with other drugs for the treatment of hypertension, was found in the blood and urine of a fatal aircraft accident victim. The extraction and identification of triamterene is difficult. It exhibits poor extraction efficiency using some standard base-extraction procedures, and the parent drug is unsuitable for analysis using gas chromatography. In this case, a thin-layer chromatography solvent system and high-performance liquid chromatography were used to identify and quantitate triamterene in blood and urine. Triamterene is a strong absorber in the ultraviolet region and has an unusual UV spectrum, which simplifies the identification and quantitation of this substance by high-performance liquid chromatography.

Deconjugation of p-hydroxytriamterene sulphate in the rat.

1. The extent of deconjugation of p-hydroxytriamterene sulphate was studied in rats, by h.p.l.c., after i.v., i.p., and oral administration. 2. After i.v. administration, deconjugation accounted for 29-54% of the recovered dose as free p-hydroxytriamterene in urine and faeces. Following i.p. administration, 70-88% was deconjugated and 72-96% was deconjugated after oral administration. Most of the p-hydroxytriamterene was recovered in faeces.