Tolerant or Intolerant? Learning From Studying Drug Concentrations in the Living and the Dead.

ABSTRACT: Tolerance is the diminished response to a drug that occurs when that drug is repeatedly used, and the body adapts to its continued presence. This means that greater blood concentrations are required to achieve desired effects, produce impairment, or cause death. Without case-specific information, the pharmacodynamic impacts of a drug on an individual are difficult to ascertain based on its concentration alone. One starting point, however, is to compare reported findings with reference ranges associated with therapeutic, toxic, and lethal outcomes. Toxicologists have observed concentrations dramatically increase over time in the living population for some drugs to concentrations that can easily be associated with impairment and lethal outcomes. It is, therefore, important to continually monitor and be familiar with drug concentrations found in the living to interpret postmortem concentrations. To emphasize this approach, we compared fentanyl concentrations from JAN 2010 to OCT 2023 in individuals investigated for driving under the influence of drugs to postmortem cases. This comparison highlights the changing nature of tolerance, stresses the importance of not relying solely on reference ranges for result interpretations, and discusses the importance of the autopsy in identifying or ruling out other potential causes of death.

Beyond the Buzz: The Fatal Consequences of Caffeine Overconsumption.

Caffeine is a naturally occurring stimulant present in dozens of plant species including Coffea arabica and Camellia sinensis, from which we obtain coffee and tea, respectively. It is one of the world's most widely consumed psychoactive substances frequently used to increase alertness, elevate mood, and ward off fatigue. In traditional preparations, caffeine is generally well-tolerated by the consumer. However, complications can arise with the addition of caffeine to products like energy drinks, medications, and supplements. Furthermore, with pure caffeine accessible online, a consumer may unknowingly or inadvertently consume caffeine in dangerous amounts. Symptoms of caffeine toxicity include classic CNS stimulation side effects such as agitation, insomnia, gastrointestinal distress, tachycardia, seizures, and death in extreme cases. To evaluate concentrations of toxicological significance, caffeine cases were assessed at a large reference laboratory (NMS Labs). From 2019-2023, 406 blood cases underwent confirmation testing via LC-MS-MS; the mean and median caffeine concentrations were 35 µg/mL and 4.8 µg/mL, respectively. While most caffeine-containing cases indicate traditional use in the general population with concentrations below 25 µg/mL (62%, N = 254), 10% (N=42) of the cases were greater than 100 µg/mL, indicating levels which may contribute to a fatal outcome. To gain insight into the significance of caffeine in determining the cause and manner of death, cases with various manners of death are presented. Despite being one of the most common toxicological findings in medicolegal death investigations, caffeine is often overlooked. Screening results should undergo scrutiny, and confirmation testing should be considered in cases where caffeine intoxication prominently features in the case history or scene investigation.

Suicide by an Unusual Compound: A Case of Barium Acetate Toxicity.

ABSTRACT: Forensic pathologists may sometimes encounter cases of suicide with ingestion of unusual compounds. Herein, we describe a case of suicide by ingestion of barium acetate. Deaths by ingestion of this compound have not previously been reported in literature. This case shows the clinical presentation of the toxicity of barium compounds and highlights the importance of scene investigation and clinicopathologic correlation in suicides by unusual ingestion.

Loperamide-Related Deaths in North Carolina.

Loperamide (Imodium®) has been accepted as a safe, effective, over-the-counter anti-diarrheal drug with low potential for abuse. It is a synthetic opioid that lacks central nervous system activity at prescribed doses, rendering it ineffective for abuse. Since 2012, however, the North Carolina Office of the Chief Medical Examiner has seen cases involving loperamide at supratherapeutic levels that indicate abuse. The recommended dose associated with loperamide should not exceed 16 mg per day, although users seeking an opioid-like high reportedly take it in excess of 100 mg per dose. When taken as directed, the laboratory organic base extraction screening method with gas chromatography-mass spectrometry/nitrogen phosphorus detector lacks the sensitivity to detect loperamide. When taken in excess, the screening method identifies loperamide followed by a separate technique to confirm and quantify the drug by liquid chromatography-tandem mass spectrometry. Of the 21 cases involving loperamide, the pathologist implicated the drug as either additive or primary to the cause of death in 19 cases. The mean and median peripheral blood concentrations for the drug overdose cases were 0.27 and 0.23 mg/L, respectively. Furthermore, an extensive review of the pharmacology associated with loperamide and its interaction with P-glycoprotein will be examined as it relates to the mechanism of toxicity.

Development of a Peptide-derived orally-active kappa-opioid receptor agonist targeting peripheral pain.

Kappa-opioid agonists are particularly efficacious in the treatment of peripheral pain but suffer from central nervous system (CNS)-mediated effects that limit their development. One promising kappa-agonist is the peptidic compound CR665. Although not orally available, CR665 given i.v. exhibits high peripheral to CNS selectivity and benefits patients with visceral and neuropathic pain. In this study we have generated a series of derivatives of CR665 and screened them for oral activity in the acetic acid-induced rat writhing assay for peripheral pain. Five compounds were further screened for specificity of activation of kappa receptors as well as agonism and antagonism at mu and delta receptors, which can lead to off-target effects. All active derivatives engaged the kappa receptor with EC50s in the low nM range while agonist selectivity for kappa over mu or delta was >11,000-200,000-fold. No antagonist activity was detected. One compound was chosen for further analysis (Compound 9). An oral dose response of 9 in rats yielded an EC50 of 4.7 mg/kg, approaching a druggable level for an oral analgesic. To assess the peripheral selectivity of this compound an i.v. dose response in rats was assessed in the writhing assay and hotplate assay (an assay of CNS-mediated pain). The EC50 in the writhing assay was 0.032 mg/kg while no activity was detectable in the hotplate assay at doses as high as 30 mg/kg, indicating a peripheral selectivity of >900-fold. We propose that compound 9 is a candidate for development as an orally-available peripherally-restricted kappa agonist.

Identification and functional characterization of a stable, centrally active derivative of the neurotensin (8-13) fragment as a potential first-in-class analgesic.

The neurotensin hexapapetide fragment NT(8-13) is a potent analgesic when administered directly to the central nervous system but does not cross the blood-brain barrier. A total of 43 novel derivatives of NT(8-13) were evaluated, with one, ABS212 (1), being most active in four rat models of pain when administered peripherally. Compound 1 binds to human neurotensin receptors 1 and 2 with IC(50) of 10.6 and 54.2 nM, respectively, and tolerance to the compound in a rat pain model did not develop after 12 days of daily administration. When it was administered peripherally, serum levels and neurotensin receptor binding potency of 1 peaked within 5 min and returned to baseline within 90-120 min; however, analgesic activity remained near maximum for >240 min. This could be due to its metabolism into an active fragment; however, all 4- and 5-mer hydrolysis products were inactive. This pharmacokinetic/pharmacodynamic dichotomy is discussed. Compound 1 is a candidate for development as a first-in-class analgesic.

Cyclic modular beta-sheets.

The development of peptide beta-hairpins is problematic, because folding depends on the amino acid sequence and changes to the sequence can significantly decrease folding. Robust beta-hairpins that can tolerate such changes are attractive tools for studying interactions involving protein beta-sheets and developing inhibitors of these interactions. This paper introduces a new class of peptide models of protein beta-sheets that addresses the problem of separating folding from the sequence. These model beta-sheets are macrocyclic peptides that fold in water to present a pentapeptide beta-strand along one edge; the other edge contains the tripeptide beta-strand mimic Hao [JACS 2000, 122, 7654] and two additional amino acids. The pentapeptide and Hao-containing peptide strands are connected by two delta-linked ornithine (deltaOrn) turns [JACS 2003, 125, 876]. Each deltaOrn turn contains a free alpha-amino group that permits the linking of individual modules to form divalent beta-sheets. These "cyclic modular beta-sheets" are synthesized by standard solid-phase peptide synthesis of a linear precursor followed by solution-phase cyclization. Eight cyclic modular beta-sheets 1a-1h containing sequences based on beta-amyloid and macrophage inflammatory protein 2 were synthesized and characterized by 1H NMR. Linked cyclic modular beta-sheet 2, which contains two modules of 1b, was also synthesized and characterized. 1H NMR studies show downfield alpha-proton chemical shifts, deltaOrn delta-proton magnetic anisotropy, and NOE cross-peaks that establish all compounds but 1c and 1g to be moderately or well folded into a conformation that resembles a beta-sheet. Pulsed-field gradient NMR diffusion experiments show little or no self-association at low (

DSA: a new internal standard for NMR studies in aqueous solution.

[structure: see text] The widely used internal standard for NMR studies in aqueous solution DSS (sodium 4,4-dimethyl-4-silapentane-1-sulfonate) can interact with cationic peptides, diminishing its value for such studies. This paper introduces DSA (4,4-dimethyl-4-silapentane-1-ammonium trifluoroacetate) as a new internal standard that does not suffer from this problem.

Laser action from two dipyrrinone dyes under flash-lamp pumping.

Two quasi-aromatic compounds, namely, two dipyrrinone dyes (Xanthoglow and Kryptoglow), exhibited strong fluorescence. Therefore they were tested for laser action under flash-lamp pumping. These two dyes outperformed Coumarin 540A and exhibited a high degree of photostability when dissolved in 1,4-dioxane. However, in all other solvents used, considerable photodecomposition was observed.

Dityrosine cross-linked Abeta peptides: fibrillar beta-structure in Abeta(1-40) is conducive to formation of dityrosine cross-links but a dityrosine cross-link in Abeta(8-14) does not induce beta-structure.

Recent reports by Galeazzi and co-workers demonstrated the susceptibility of Abeta(1-42) to undergo dityrosine formation via peroxidase-catalyzed tyrosine cross-linking. We have formed dityrosine cross-links in Abeta(1-40) using these enzymatic conditions as well as a copper-H(2)O(2) method. The efficiency of dityrosine cross-link formation is strongly influenced by the aggregation state of Abeta; more dityrosine is formed when copper-H(2)O(2) or horseradish peroxidase-catalyzed oxidation is applied to fibrillar Abeta vs soluble Abeta. Once formed, dityrosine cross-links are susceptible to further oxidative processes and it appears that cross-links formed in soluble Abeta react through these pathways more readily than those formed in fibrillar Abeta. Because preorganization of fibrils affects the efficiency of dityrosine formation, we examined the effect of dityrosine formation upon local peptide conformation by assessing the solution structure of a small dityrosine dimer derived from Abeta(8-14). Two-dimensional (1)H NMR studies of the short dityrosine dimer offer no evidence of structure. Thus, the fibrillar structure of Abeta enhances formation of dityrosine cross-links, but dityrosine cross-links do not seem to enhance local secondary structure.

A new turn structure for the formation of beta-hairpins in peptides.

Previous studies by Gellman and co-workers have elegantly shown that mirror-image beta-turns based upon d-Pro-Gly are especially good at stabilizing beta-hairpins and have demonstrated that peptide 1 [Arg-Trp-Gln-Tyr-Val-d-Pro-Gly-Lys-Phe-Thr-Val-Gln-NH2] folds into a well-defined beta-hairpin [Espinosa, J. F.; Gellman, S. H. Angew. Chem., Int. Ed. 2000, 39, 2330-2333]. The present study establishes that the amino acid ornithine (Orn) also forms a turn structure that is excellent at stabilizing beta-hairpins when linked through the delta-amino group and that this turn is comparable to d-Pro-Gly in ability to induce beta-hairpin formation. Thus, 1H NMR chemical shift and NOE studies establish that Orn-containing analogue 2 [Arg-Trp-Gln-Tyr-Val-deltaOrn-Lys-Phe-Thr-Val-Gln-NH2] is comparable in structure to peptide 1. The present study also establishes that the Orn turn is superior to Asn-Gly turns and that replacement of the deltaOrn with epsilonLys or d-deltaOrn generates structures that do not fold significantly.

Hepatobiliary excretion of dipyrrinone sulfonates in Mrp2-deficient (TR(-)) rats.

The biliary excretion of the sodium salts of 8-(2-ethanesulfonic acid)-3-ethyl-2,7,9-trimethyl-1,10-dihydro-11H-dipyrrin-1-one (xanthosulfonic acid) and a fluorescent analogue (8-desethyl-N,N'-carbonyl-kryptopyrromethenone-8-sulfonic acid) was compared in Mrp2-deficient (TR(-)) and normal rats. Both organic anions were excreted rapidly in bile in Mrp2-deficient rats, but the biliary excretion of the fluorescent sulfonate was impaired relative to normal controls. The rat clearly has efficient Mrp2-independent mechanisms for biliary efflux of these anions that are not used by bilirubin or its mono- and diglucuronides.

Synthesis and spectroscopic properties of a new class of strongly fluorescent dipyrrinones.

A new, highly fluorescent (Phi(F) > or = 0.8) chromophore has been synthesized in one step from dipyrrinones by reaction with N,N-carbonyldiimidazole to form the 3H,5H-dipyrrolo[1,2-c:2',1'-f]pyrimidine-3,5-dione nucleus.