[On the issue of the detection of pregabalin and lorazepam in the cases of their joint presence for the purpose of chemical toxicological studies]. / Izuchenie pregabalina i lorazepama pri sovmestnom prisutstvii dlia tselei khimiko-toksikologicheskogo issledovaniia.

Data on the detection of joint presence of pregabalin and lorazepam in the biological objects and material evidence. Aim of this study is to develop a method of the detection of pregabalin and lorazepam in urine. The proposed approach to sample preparation of a biological object and the detection of lorazepam and pregabalin allows the detection of toxicants in cases of their joint presence. It can be used in the analysis of urine in cases of acute poisoning for detoxification therapy or chemical toxicological analysis as a preliminary and confirmatory study for the presence of abuse of these drugs.

Characterization and identification of eight designer benzodiazepine metabolites by incubation with human liver microsomes and analysis by a triple quadrupole mass spectrometer.

Designer benzodiazepines (DBZDs) have become of particular importance in the past few years. The metabolite monitoring of DBZD in biological fluids could be of great interest in clinical and forensic toxicology. However, DBZD metabolites are not known or not commercially available. The identification of some DBZD metabolites has been mostly explored by self-administration studies or by in vitro studies followed by high-resolution mass spectrometry. The question arose whether a unit resolution instrument could be efficient enough to allow the identification of DBZD metabolites. In this study, we used an in vitro experiment where eight DBZDs (diclazepam, flubromazepam, etizolam, deschloroetizolam, flubromazolam, nifoxipam, meclonazepam and clonazolam) were incubated with human liver microsomes (HLMs) and metabolite identification was carried out by using a UHPLC coupled to a QTRAP triple quadrupole linear iontrap tandem mass spectrometer system. Post-mortem samples obtained from a real poisoning case, involving deschloroetizolam and diclazepam, were also analysed and discussed. Our study using HLM allowed the identification of 26 metabolites of the 8 DBZDs. These were denitro-, mono- or di-hydroxylated and desmethyl metabolites. In the forensic case, diclazepam was not detected whereas its metabolites (lormetazepam and lorazepam) were present at high concentrations in urine. We also identified hydroxy-deschloroetizolam in urine, while the parent compound was not detected in this matrix. This supports the approach that LC coupled to a simple QTRAP could be used by laboratories to identify other not-known/not-commercialized new psychoactive substance (NPS) metabolites.

Therapeutic monitoring of benzodiazepines in the management of pain: current limitations of point of care immunoassays suggest testing by mass spectrometry to assure accuracy and improve patient safety.

BACKGROUND: Concomitant use of opioids and benzodiazepines can result in significant untoward effects. Point of care (POC) urine testing devices are commonly used tools to monitor patient use of medications. These useful devices are relatively inexpensive and yield immediate results that can be acted upon at the time of the appointment, although numerous limitations have been identified for specific medications or medication classes. We established the diagnostic accuracy of a commonly used POC testing method for benzodiazepines. METHODS: One thousand patients, from a single interventional pain practice receiving opioid therapy provided urine specimens as part of the usual practice of monitoring consistency with prescribed medications. These de-identified urine specimens were tested using LC-MS/MS and the results were compared using the standard calculations for sensitivity, specificity, and predicted value. Five specimens were excluded from the study because the prescribed flurazepam could not be confirmed by LC-MS/MS (the LC-MS/MS instrumentation was not set to identify flurazepam), resulting in 995 specimens. RESULTS: Point of care assays yielded false negative results for patients prescribed benzodiazepines nearly 20% of the time (98 out of 498 patients). The point of care cup often failed to produce positive results for persons who were shown by LC-MS/MS to be taking lorazepam or clonazepam. Although only 26 out of 498 patients (5%) were prescribed ≥2 benzodiazepines, 73 out of 498 patients (15%) were found to be positive for that drug class. CONCLUSIONS: POC immunoassay for benzodiazepines could fail to provide accurate information regarding patient specific medication use. The false positive and false negative rates of the immunoassay were particularly high for clonazepam and lorazepam. Further testing of patient specimens using more accurate methods such as LC-MS/MS is necessary to provide definitive data that can assist in clinical decision making, and potentially protect these patients from untoward effects, morbidity and mortality.

Metabolites of lorazepam: Relevance of past findings to present day use of LC-MS/MS in analytical toxicology.

The advent of liquid chromatography-tandem mass spectrometry (LC-MS/MS), with the sensitivity it confers, permits the analysis of both phase I and II drug metabolites that in the past would have been difficult to target using other techniques. These metabolites may have relevance to current analytical toxicology employing LC-MS/MS, and lorazepam was chosen as a model drug for investigation, as only the parent compound has been targeted for screening purposes. Following lorazepam administration (2 mg, p.o.) to 6 volunteers, metabolites were identified in urine by electrospray ionization LC-MS/MS, aided by the use of deuterated analogues generated by microsomal incubation for use as internal chromatographic and mass spectrometric markers. Metabolites present were lorazepam glucuronide, a quinazolinone, a quinazoline carboxylic acid, and two hydroxylorazepam isomers, one of which is novel, having the hydroxyl group located on the fused chlorobenzene ring. The quinazolinone, and particularly the quinazoline carboxylic acid metabolite, provided longer detection windows than lorazepam in urine extracts not subjected to enzymatic hydrolysis, a finding that is highly relevant to toxicology laboratories that omit hydrolysis in order to rapidly reduce the time spent on gas chromatography-mass spectrometry (GC-MS) analysis. With hydrolysis, the longest windows of detection were achieved by monitoring lorazepam, supporting the targeting of the aglycone with free drug for those incorporating hydrolysis in their analytical toxicology procedures.

Quantitation of benzodiazepines in blood and urine using gas chromatography-mass spectrometry (GC-MS).

The benzodiazepine assay utilizes gas chromatography-mass spectrometry (GC-MS) for the analysis of diazepam, nordiazepam, oxazepam, temazepam, lorazepam, alpha-hydroxyalprazolam, and alpha-hydroxytriazolam in blood and urine. A separate assay is employed for the analysis of alprazolam. Prior to solid phase extraction, urine specimens are subjected to enzyme hydrolysis. The specimens are fortified with deuterated internal standard and a five-point calibration curve is constructed. Specimens are extracted by mixed-mode solid phase extraction. The benzodiazepine extracts are derivatized with N-methyl-N-(tert-butyldimethylsilyl)trifluoroacetamide (MTBSFTA) producing tert-butyldimethyl silyl derivatives; the alprazolam extracts are reconstituted in methanol without derivatization. The final extracts are then analyzed using selected ion monitoring GC-MS.

Analysis of lorazepam and its 30-glucuronide in human urine by capillary electrophoresis: evidence for the formation of two distinct diastereoisomeric glucuronides.

Lorazepam (LOR) is a 3-hydroxy-1,4-benzodiazepine that is chiral and undergoes enantiomerization at room temperature. In humans, about 75% of the administered dose of LOR is excreted in the urine as its 30-glucuronide. CE-MS with negative ESI was used to confirm the presence of LOR-30-glucuronide in urines that stemmed from a healthy individual who ingested 1 or 2 mg LOR, whereas free LOR could be detected in extracts prepared from enzymatically hydrolyzed urines. As the 30-glucuronidation reaction occurs at the chiral center of the molecule, two diastereoisomers can theoretically be formed, molecules that can no longer interconvert. The stereoselective formation of LOR glucuronides in humans and in vitro was investigated. MEKC analysis of extracts of the nonhydrolyzed urines suggested the presence of the two different LOR glucuronides in the urine. The formation of the same two diastereoisomers was also observed in vitro employing incubations of LOR with human liver microsomes in the presence of uridine 5'-diphospho-glucuronic acid as coenzyme. The absence of other coenzymes excluded the formation of phase I or other phase II metabolites of LOR. Both results revealed a stereoselectivity, one diastereoisomer being formed in a higher amount than the other. After enzymatic hydrolysis using beta-glucuronidase, these peaks could not be detected any more. Instead, LOR was monitored. Analysis of the extracts prepared from enzymatically hydrolyzed urines by MEKC in the presence of 2-hydroxypropyl-beta-CD revealed the enantiomerization process of LOR (observation of two peaks of equal magnitude connected with a plateau zone). The data presented provide for the first time the evidence of the stereoselectivity of the LOR glucuronidation in humans.

Quantitative assay of lorazepam and its metabolite glucuronide by reverse-phase liquid chromatography-tandem mass spectrometry in human plasma and urine samples.

A LC/MS/MS method for the quantitative determination of lorazepam in human plasma and urine samples was developed and validated. The enantioselective assay allowed to separate the enantiomers and to verify the stereochemical instability of lorazepam. The linearity assessed for lorazepam unchanged was 0.2-20 ng of each enantiomer/ml plasma and 0.2-15 ng of each enantiomer/ml urine. The linearity assessed for total lorazepam (after enzymatic hydrolysis) was 1-30 ng of each enantiomer/ml plasma and 10-150 ng of each enantiomer/ml urine. The coefficients of variation obtained for the intra- and interassay precision were less than 15%. The method was applied to the investigation of the kinetic disposition and metabolism of racemic lorazepam administered as a single oral dose of 2 mg to a parturient. The occurrence of racemization required the calculation of the pharmacokinetic parameters as enantiomeric mixtures of lorazepam (t(1/2a) 3.5h; K(a) 0.198 ngh(-1); t(1/2) 11.5h; beta 0.060 h(-1); AUC(0-infinity) 192.1ngh/ml; CLt/f 2.41ml/minkg; Vd/f 173.5l; Fel 0.41%, and Cl(R) 0.0099 ml/minkg) and its metabolite lorazepam-glucuronide (t(1/2f) 1.2h; K(f) 0.578 h(-1); t(1/2) 16.6h; beta 0.042 h(-1); AUC(0-infinity) 207.6 ngh/ml; Fel 51.80%, and Cl(R) 98.32 ml/minkg). However, the determined confidence limits make the method suitable for application to clinical pharmacokinetic studies, even if the quantification of both the enantiomers is required.

[The determination of lorazepam in human urine by gas chromatography/nitrogen-phosphorus detector].

A method to assay lorazepam in human urine has been developed. After addition of hydroxyethylflurazepam (internal standard) and hydrolysis with beta-glucuronidase, the lorazepam and hydroxyethylflurazepam were extracted with ethyl ether at pH 10.8. The analysis was performed on an HP-5 capillary column with nitrogen-phosphorus detector(NPD). The detection limit and recovery of analytes in urine were 5 micrograms/L and (83.4 +/- 3.1)% respectively. The method was successfully applied to urine specimens collected from healthy human volunteers who have ingested 2 mg of lorazepam. The method was sensitive enough to assay urine specimen excreted at 32 h after taking the medicine by volunteers.

Determination of lorazepam in plasma and urine as trimethylsilyl derivative using gas chromatography-tandem mass spectrometry.

A procedure based on gas chromatography-tandem mass spectrometry for identification and quantitation of lorazepam in plasma and urine is presented. The analyte was extracted from biological fluids under alkaline conditions using solid-phase extraction with an Extrelut-1 column in the presence of oxazepam-d5 as the internal standard. Both compounds were then converted to their trimethylsilyl derivatives and the reaction products were identified and quantitated by gas chromatography-tandem mass spectrometry using the product ions of the two compounds (m/z 341, 306 and 267 for lorazepam derivative and m/z 346, 309 and 271 for oxazepam-d5 derivative) formed from the parent ions by collision-induced dissociation in the ion trap spectrometer. Limit of quantitation was 0.1 ng/ml. This method was validated for urine and plasma samples of individuals in treatment with the drug.

Comparison of four immunoassays for the detection of lorazepam in urine.

Four healthy patient subjects were each given a single, 1-mg lorazepam tablet. Urine samples from all patient subjects were collected at 12 intervals (0-2, 2-5, 5-8, 8-11, 11-14, 14-24, 24-26, 26-29, 29-32, 32-35, 35-38, and 38-48 hours). An aliquot from each urine collection was screened using cloned enzyme donor immunoassay (CEDIA), enzyme-multiplied immunoassay technique (EMIT) II, EMIT dau, and fluorescence polarization immunoassay (FPIA) without and with hydrolysis using beta-glucuronidase. Using a 200 ng/mL calibrator cut-off, none of the four immunoassays gave a positive response before hydrolyzation of the urine samples. For offline hydrolysis using Helix pomatia beta-glucuronidase, 35, 3, 0, and 4 of 48 urine samples gave positive responses on the previously listed immunoassays. The CEDIA method also gave 32 of 48 positive responses for online hydrolysis using Escherichia coli beta-glucuronidase. Online hydrolysis can be conveniently automated by including the beta-glucuronidase in the first of the two reagents combined with the urine sample.

Simultaneous extraction of selected benzodiazepines and benzodiazepine-glucuronides from urine by immunoadsorption.

A rapid and selective cleanup procedure based on immunoadsorption is described for the simultaneous extraction of diazepam and its free or glucuronidated metabolites nordiazepam, temazepam, and oxazepam from urine. The method can also be used for the extraction of lorazepam and lorazepam-glucuronide. Because the samples do not have to be hydrolyzed before extraction, valuable information is preserved. With the exception of lorazepam-glucuronide, recoveries between 86 and 100% were obtained at spiking levels up to 200 ng of benzodiazepine or glucuronide per milliliter of urine. Using methanol/water (90:10, v/v) as an eluent, the immunoadsorber could be used at least 20 times. High-performance liquid chromatograms of urine samples from patients receiving low therapeutic dosages of diazepam or lorazepam are shown to demonstrate the high purity of the extracts.

CEDIA dau Benzodiazepine screening assay: a reformulation.

The CEDIA dau Benzodiazepine assay has been reformulated to include online hydrolysis of urinary benzodiazepine glucuronide conjugates. The new antibody possesses enhanced cross-reactivities toward the low-dose benzodiazepines, which are excreted at low urinary drug-metabolite concentrations. The screening method was evaluated using lorazepam as the probe benzodiazepine. Four subjects each consumed a 1-mg lorazepam tablet. Sequential urine voids over the same time intervals were collected for the next 48 h. Twelve postdose urine samples were collected from each subject. Positive results were obtained from 5-24 h to 2-35 h using a 200-ng/mL nitrazepam calibration cutoff. There was no practical difference between hydrolyzing online with the supplied E. coli beta-glucuronidase or offline with Helix pomatia beta-glucuronidase purchased separately. Without hydrolysis, all urine samples tested negative. The cross-reactivities of lorazepam in terms of nitrazepam calibration equivalents, varied from 108 to 178% for lorazepam concentrations between 50 and 2500 ng/mL. Lorazepam glucuronide gave cross-reactivities (expressed as lorazepam base) between 72 and 136% using the online hydrolysis procedure with E. coli beta-glucuronidase. Offline hydrolysis with Helix pomatia gave cross-reactivities between 84 and 134%. Without hydrolysis, lorazepam glucuronide gave less than 4% cross-reactivity in the assay.

Comparison between the CEDIA and EMIT II immunoassays for the determination of benzodiazepines.

We evaluated a new, qualitative immunoassay for benzodiazepines in urine using CEDIA technology on the Hitachi 747 and compared its performance to an immunoassay using EMIT II methodology on the same instrument. A total of 500 urine samples received for routine drug screen analysis were prospectively examined for benzodiazepines by both methods. Samples producing positive results by either immunoassay method were analyzed by gas chromatography-mass spectrometry (GC-MS). Available medical records were reviewed for patients whose samples produced discrepant immunoassay results or that were positive in both immunoassays but negative by GC-MS. Samples that produced negative results in both immunoassays were not subjected to GC-MS analysis. Therefore, identification of an immunoassay result as a false negative only occurred when the sample produced a positive value in only one of the two immunoassays and was confirmed as positive by either GC-MS or medical record review. Following initial immunoassay screening and confirmation by GC-MS, a medical record review and reanalysis of GC-MS data was performed. After this in-depth analysis of the data, the CEDIA method produced 60 true-positives, 7 false positives and no false negatives. The EMIT II method produced 47 true positives, 1 fase positive and 13 false negatives. These differences appear to be due to the CEDIA assay being more sensitive for detection of lorazepam.

[Detection of lorazepam and lormetazepam metabolites in urine using thin-layer chromatography]. / Prukaz metabolitu lorazepamu a lormetazepamu v moci metodou chromatografie na tenké vrstve.

The determination of benzodiazepine derivatives lorazepam and lormetazepam in urine is based on detection of their metabolites 2-amino-2',5-dichlorobenzophenone and 2-methylamino-2'5-dichlorbenzophenone in hydrolyzed urine. Both substances are structurally very similar to the metabolites of diazepam 2-amino-5-chlorbenzophenone and 2-methylamino-5-chlorbenzophenone and their mobility on thin layer chromatograms is similar as well. This could cause their confusion and misinterpretation of the results. Therefore suitable combination of mobile phases and thin layer plates was sought in this study for the unambiguous identification of respective benzophenones by thin layer chromatography.

Comparison of different immunoassays and GC-MS screening of benzodiazepines in urine.

A total of 53 urine samples were tested by different immunoassay methods and by gas chromatography/mass spectrometry to determine repeatability of the different methods and to assess whether the immunoassays performed on samples obtained from elderly patients of the emergency section could be considered as reliable enough for identifying a benzodiazepine consumption. Repeatability was excellent for GC/MS and good for immunoassays. The specificity was not different for the three immunoassays (96%). The sensitivity varied from 36, 64 to 75% for OnLine, RIA Immunalysis and RIA DPC, respectively. An other difference between immunoassays and GC/MS was the ability of GC/MS to detect lorazepam and low concentrations of benzodiazepines whereas immunoassays did not.

A study of the potential confounding effects of diet, caffeine, nicotine and lorazepam on the stability of plasma and urinary homovanillic acid levels in patients with schizophrenia.

Ten men inpatients who met DSM-III-R criteria for schizophrenia participated. On five occasions at least one week apart, each subject had an intravenous line placed at 0730 after an overnight fast. On each occasion blood samples were drawn at 0800 and hourly thereafter through 1200 noon for measurement of plasma homovanillic acid (HVA). Total four-hour urine collections were obtained for measurement of urinary HVA. Subjects received five experimental conditions, in randomized sequence: no intervention, smoking one cigarette per hour, drinking one caffeinated cola per hour, lorazepam 2 mg IV push, or a high monoamine meal. Baseline (0800) plasma HVA measures showed only minor intrinsic variability. The average standard deviation in baseline plasma HVA over five occasions of measurement was low relative to the changes in HVA produced during treatment with antipsychotic medications. The high monoamine meal significantly elevated plasma HVA, with a similar trend for urinary HVA. Neither caffeine, nicotine, nor lorazepam significantly affected plasma or urinary HVA.