Pain Management Testing by Liquid Chromatography Tandem Mass Spectrometry.

For appropriate pain medication monitoring, the analytical method must be sensitive enough to detect the prescribed medication and metabolites at a sufficiently low concentration to recognize compliance, even with a low-dose prescription. The method must also provide excellent selectivity to identify simultaneously present drugs even with similar chemical structures. The analytical method should uncover common illicit drugs/nonprescribed medications. Traditional immunoassays cannot satisfy these criteria, but liquid chromatography tandem mass spectrometry can. It requires expensive instrumentation, careful test design, and extensive validation and produces a large amount of data that must be interpreted according to the clinical context.

Biochemical Markers of Myocardial Damage.

Heart diseases, especially coronary artery diseases (CAD), are the leading causes of morbidity and mortality in developed countries. Effective therapy is available to ensure patient survival and to prevent long term sequelae after an acute ischemic event caused by CAD, but appropriate therapy requires rapid and accurate diagnosis. Research into the pathology of CAD have demonstrated the usefulness of measuring concentrations of chemicals released from the injured cardiac muscle can aid the diagnosis of diseases caused by myocardial ischemia. Since the mid-1950s successively better biochemical markers have been described in research publications and applied for the clinical diagnosis of acute ischemic myocardial injury. Aspartate aminotransferase of the 1950s was replaced by other cytosolic enzymes such as lactate dehydrogenase, creatine kinase and their isoenzymes that exhibited better cardiac specificity. With the availability of immunoassays, other muscle proteins, that had no enzymatic activity, were also added to the diagnostic arsenal but their limited tissue specificity and sensitivity lead to suboptimal diagnostic performance. After the discovery that cardiac troponins I and T have the desired specificity, they have replaced the cytosolic enzymes in the role of diagnosing myocardial ischemia and infarction. The use of the troponins provided new knowledge that led to revision and redefinition of ischemic myocardial injury as well as the introduction of biochemicals for estimation of the probability of future ischemic myocardial events. These markers, known as cardiac risk markers, evolved from the diagnostic markers such as CK-MB or troponins, but markers of inflammation also belong to these groups of diagnostic chemicals. This review article presents a brief summary of the most significant developments in the field of biochemical markers of cardiac injury and summarizes the most recent significant recommendations regarding the use of the cardiac markers in clinical practice.

Quantitative, Multidrug Pain Medication Testing by Liquid Chromatography: Tandem Mass Spectrometry (LC-MS/MS).

Chronic pain is often treated with narcotic analgesics. The most commonly used narcotic analgesics are the opiates (natural or modified compounds of the poppy plant) or opioids (synthetic chemicals that act on opiate receptors). While opiates and opioids are excellent analgesics, they can also have significant side effects that include respiratory depression, coma, or death. Tolerance, physical dependence, and addiction (psychological dependence) are other severe side effects of opioid use. Patients who develop dependence or addiction often times abuse other, non-opioid narcotics and may trade their prescription medication for illegal street drugs (called "diversion"). In order to minimize side effects, detect possible multidrug abuse and prove diversion, simultaneous monitoring of numerous prescription and illicit drugs is required. The method described in this chapter is for the quantitative measurement of 43 different drugs in urine. The panel includes narcotic pain medications, benzodiazepines, NIDA drugs, and other, commonly abused medications. The analytes of interests are injected in the presence of deuterated internal standards to correct for possible extraction inefficiencies, ion suppression, or other interferences. The sample is prepared by adding dilution buffer with the deuterated internal standards to the sample, followed by reversed-phase, gradient HPLC separation on a Phenyl-Hexyl column using water and methanol as mobile phases. Detection of the analytes of interest is done by isotope-dilution mass spectrometry on a triple-quadrupole tandem mass spectrometer following electrospray ionization in the positive mode. Mass spectrometric (MS) data are collected in the scheduled MRM (sMRM) mode. Two MRM transitions are monitored for each analyte and one MRM transition is monitored for each IS. Quantitation of the unknown analytes is achieved by comparing the peak area ratios of the analytes to that of the internal standards and reading the unknown concentration from a seven-point calibration curve.

The Laboratory's Role in Opioid Pain Medication Monitoring.

Opioid analgesics are the most potent pain medications therefore they are often used for the treatment of chronic malignant and non-malignant pain. Their strong addictive potential requires close monitoring of patients on opioid therapy for possible non-compliance with prescriptions, for drug diversion, and for proof of avoidance of non-prescribed or illicit opioids. Monitoring can be performed by urine drug screens or qualitative or quantitative drug confirmation assays. Natural, semi-synthetic and synthetic opioids have dissimilar chemical structures and they undergo extensive metabolism. Phase one metabolic reactions of opioids can produce other opioids with similar structures to other, non-prescribed medications. Only detailed and concurrent analysis of parent drugs and metabolites can provide accurate clinical information regarding patient compliance. Traditional immunoassays, often used for urine drug screening, react with only a small number of opioids or only with a single medication and they exhibit variable cross reactivity with their phase two metabolites. Additionally the limit of detection of these immunoassays may not be sufficient for medical purposes, therefore clinical interpretation of immunoassay test results can be challenging. Recently liquid chromatography, mass spectrometry (LCMSMS) based assays have been adapted by many clinical laboratories. These LCMSMS tests can provide information about the presence of several opioids and their metabolites in a single sample at clinically meaningful detection limits, allowing accurate assessment of patient compliance. This review article will investigate in details the various opioids, their metabolism and the challenges the testing laboratories and ordering clinicians face.

Toward standardization of cardiac troponin I measurements part II: assessing commutability of candidate reference materials and harmonization of cardiac troponin I assays.

BACKGROUND: Cardiac tropoin I (cTnI) measurements show an approximately 20- to 40-fold difference between assays, and better standardization and harmonization are needed. Toward this goal, the AACC cTnI Standardization Committee collaborated with the National Institute of Standards and Technology (NIST) in an earlier study to select 2 candidate reference materials (cRMs). METHODS: Two troponin cRMs, a troponin C-troponin I-troponin T (CIT) complex from human heart tissue and a CIT complex from recombinant technology, were supplied to NIST for assessment of composition and purity, and cTnI value assignment. These cRMs and 6 cTnI-positive human serum pools were shipped to manufacturers of 15 cTnI assays. Commutability of the materials was examined by determining the numerical relationship for the cRM preparations between each manufacturer-specified field method and each of the other 14 field methods. These relationships were then compared with the corresponding numerical relationships for the human serum pools. Harmonization of methods was accomplished by determining regression parameters relative to the analytical system yielding values closest to the median for each serum pool. These regression parameters were used to recalculate pool values to harmonize the assays. Interassay CVs before and after harmonization were determined. RESULTS: Characterization of the CIT and CI cRMs showed that these materials were of specified composition. The proportion of cTnI methods that demonstrated commutability for the CIT cRM was 45%; for the CI cRM, 39% of methods demonstrated commutability. Interassay cTnI variability for the field methods ranged from 82% to 97%, median 88%. After harmonization, variability of the serum pools for the cTnI methods was decreased to between 9.0% and 23%, median 15.5%. CONCLUSIONS: The proportion of methods demonstrating commutability was too low for use as a common calibrator for the cTnI field methods. However a simple strategy using serum pools can improve harmonization of field cTnI methods by more than 5-fold. The CIT cRM was selected by the AACC cTnI standardization committee, and a new lot has been classified as the cTnI certified reference material Standard Reference Material 2921 by NIST.