The duration of ketamine detection in hair after treatment cessation: Case study and review of the literature in forensic and clinical casework

International audienceThe disappearance of drug from hair does not occur immediately after abstinence because dormant hair may contribute to the positivity of freshly grown hair. The aim of this study was to assess ketamine disappearance from hair after treatment cessation and to review the literature data. A 22-year-old female received three intravenous doses of ketamine (171 mg) for major depression treatment. Seventeen weeks later, a 26 cm lock of hair was sampled, and ketamine was determined by liquid chromatography tandem mass spectrometry (LC–MS/MS) on seven segments: A (proximal, 0–2 cm), B (2–4 cm), C (4–6 cm, period of ketamine therapy), and D to G (4 × 5 cm). Ketamine concentration was 58 pg/mg in Segment C and remained detectable over 4 months after treatment cessation at 67 pg/mg in Segment B and 2 pg/mg in Segment A, representing a 97% drop from the initial concentration. Ketamine elimination half-life in hair was estimated at 0.88 month, implying that indetectable concentration should be expected 7 months after cessation. Axial diffusion was excluded as ketamine was not detected in Segments D–G. Given the low ketamine concentrations, norketamine was not detected. While no data on ketamine disappearance from hair have been published to date, previous studies have shown that discontinuation resulted in negative hair results after 3 months for heroin, 3–4 months for cocaine and tramadol, 6 months for amphetamine and methamphetamine, and 6–7 months for THC-COOH. This study provides useful findings for ketamine hair concentration interpretation, which should be validated by more consistent and comprehensive investigations

Quantification of plasma remdesivir and its metabolite GS-441524 using liquid chromatography coupled to tandem mass spectrometry. Application to a Covid-19 treated patient

International audienceObjectives A method based on liquid chromatography coupled to triple quadrupole mass spectrometry detection using 50 µL of plasma was developed and fully validated for quantification of remdesivir and its active metabolites GS-441524. Methods A simple protein precipitation was carried out using 75 µL of methanol containing the internal standard (IS) remdesivir- 13 C 6 and 5 µL ZnSO4 1 M. After separation on Kinetex ® 2.6 µm Polar C18 100A LC column (100 × 2.1 mm i.d.), both compounds were detected by a mass spectrometer with electrospray ionization in positive mode. The ion transitions used were m / z 603.3 → m / z 200.0 and m / z 229.0 for remdesivir, m / z 292.2 → m / z 173.1 and m / z 147.1 for GS-441524 and m / z 609.3 → m / z 206.0 for remdesivir- 13 C 6 . Results Calibration curves were linear in the 1–5000 μg/L range for remdesivir and 5–2500 for GS-441524, with limit of detection set at 0.5 and 2 μg/L and limit of quantification at 1 and 5 μg/L, respectively. Precisions evaluated at 2.5, 400 and 4000 μg/L for remdesivir and 12.5, 125, 2000 μg/L for GS-441524 were lower than 14.7% and accuracy was in the [89.6–110.2%] range. A slight matrix effect was observed, compensated by IS. Higher stability of remdesivir and metabolite was observed on NaF-plasma. After 200 mg IV single administration, remdesivir concentration decrease rapidly with a half-life less than 1 h while GS-441524 appeared rapidly and decreased slowly until H 24 with a half-life around 12 h. Conclusions This method would be useful for therapeutic drug monitoring of these compounds in Covid-19 pandemic

First detection/quantification of roxadustat in hair with a new liquid chromatography with tandem mass spectrometry method: Application to a treated patient

International audienceRoxadustat is an oral inhibitor of hypoxia-inducible factor prolyl hydroxylase which increases erythropoiesis. It can therefore be used as a doping agent. No data are available on how to measure roxadustat in hair and on the concentration found in treated patients. The aim of this study was to develop a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the quantification of roxadustat in hair and to apply it to a chronically treated patient. After decontamination with dichloromethane, testosterone-D3 used as an internal standard and phosphate buffer pH 5.0 were added to 20 mg of hair and incubated for 10 min at 95 °C. Four ml of dichloromethane were used for extraction and reconstituted into the mobile phase, 10 µL were injected into the chromatographic system. The method was linear in the range 0.5–200 pg/mg, accurate and precise (evaluated at 3 levels) and was successfully applied to measure roxadustat in a brown-haired patient treated pharmacologically with 100–120 mg 3 days a week. Results were stable between 41 and 57 pg/mg in the 6 proximal 1 cm segments. This first method describing the measurement of roxadustat in hair appears to be suitable for the quantification of this compound in clinical or doping control cases

Evaluation of the cardiovascular risk induced by cannabis use from a series of 43 autopsy cases

International audienceThe aim of this monocentric observational autopsy study was to confirm the existence of a link between cannabis use and cardiovascular risk. It was based on the analysis of autopsy findings, cardiovascular pathological findings, and toxicological data in 43 autopsy cases of people who died with tetrahydrocannabinol (THC) in their blood over a 2-year period. Hair analysis was performed when available (n = 40) to distinguish between occasional and chronic cannabis use and to take into account other possible exposures, including smoking, drug consumption, and the use of other drugs of abuse (mainly cocaine, heroin, and amphetamine). A statistically significant association (Fisher’s exact test, p < 0.001) was found between cannabis use, an undetermined manner of death, and the presence of an arrhythmogenic cardiac condition. An association was also found between cannabis use and the presence of advanced coronary heart disease (p = 0.01), heart disease (including ischemic heart disease, p = 0.003), or cardiomyopathy (p = 0.01). Through its systemic vascular action, cannabis could be a factor in triggering sudden death in subjects with arrhythmogenic cardiac conditions. In view of this finding, the mode of death of subjects who died in the presence of THC in the blood would in most cases be an “accident.” These results highlight the potential adverse cardiac effects associated with cannabis use

Development and validation of liquid chromatography-tandem mass spectrometry targeted screening of 16 fentanyl analogs and U-47700 in hair: Application to 137 authentic samples

International audienceThis study was to validate a LC–MS/MS method for the determination of 17 new synthetic opioids (NSOs) in hair including 3-fluorofentanyl, 3-methylfentanyl, acetylfentanyl, acetylnorfentanyl, alfentanyl, butyrylfentanyl, butyrylnorfentanyl, carfentanil, fentanyl, furanylfentanyl, furanylnorfentanyl, methoxyacetylfentanyl, norcarfentanil, norfentanyl, ocfentanil, sufentanil, and U-47700, and to apply it to 137 authentic samples. Twenty milligrams of hair was decontaminated in dichloromethane and underwent liquid extraction. 10 μL of the reconstituted residue were injected onto the system. The separation was performed in 12 minutes in a gradient mode at a flow rate of 300 μL/min using a Hypersyl Gold PFP column (100 × 2.1 mm i.d., 1.9 μm) maintained at 30°C. Compounds were detected in positive ionization and MRM modes using a TSQ Endura mass spectrometer (ThermoFisher). The method was validated according to EMA guidelines. The LLOQ was in the range 1–50 pg/mg, and the calibration ranged from the LLOQ-1000 pg/mg. Intra- and inter-day accuracy (bias) and precision were < 15%. Extraction recoveries of parent drugs and metabolites were 74–120% and 7–62%, respectively. The matrix effect was in the range 59–126% (CVs ≤ 12.9%). Fentanyl was found in six cases at concentrations of < 1–1650 pg/mg (n = 14 segments). Five fentanyl analogs were quantified in two cases: 3-fluorofentanyl (25–150 pg/mg, n = 5), furanylfentanyl (15–500 pg/mg, n = 5), methoxyacetylfentanyl (500–600 pg/mg, n = 2), acetylfentanyl (1 pg/mg, n = 2), carfentanyl (2.5–3 pg/mg, n = 2). This fully validated method allowed us to test for the first time 3-fluorofentanyl and norcarfentanil in hair among 15 other NSOs, and brings new data regarding 3-fluorofentanyl and methoxyacetylfentanyl hair concentrations

Population pharmacokinetics of lopinavir/ritonavir in Covid-19 patients

International audienceObjective: To develop a population pharmacokinetic model for lopinavir boosted by ritonavir in coronavirus disease 2019 (Covid-19) patients.Methods: Concentrations of lopinavir/ritonavir were assayed by an accredited LC-MS/MS method. The population pharmacokinetics of lopinavir was described using non-linear mixed-effects modeling (NONMEM version 7.4). After determination of the base model that better described the data set, the influence of covariates (age, body weight, height, body mass index (BMI), gender, creatinine, aspartate aminotransferase (AST), alanine aminotransferase (ALT), C reactive protein (CRP), and trough ritonavir concentrations) was tested on the model.Results: From 13 hospitalized patients (4 females, 9 males, age = 64 ± 16 years), 70 lopinavir/ritonavir plasma concentrations were available for analysis. The data were best described by a one-compartment model with a first-order input (KA). Among the covariates tested on the PK parameters, only the ritonavir trough concentrations had a significant effect on CL/F and improved the fit. Model-based simulations with the final parameter estimates under a regimen lopinavir/ritonavir 400/100 mg b.i.d. showed a high variability with median concentration between 20 and 30 mg/L (Cmin/Cmax) and the 90% prediction intervals within the range 1-100 mg/L.Conclusion: According to the estimated 50% effective concentration of lopinavir against SARS-CoV-2 virus in Vero E6 cells (16.7 mg/L), our model showed that at steady state, a dose of 400 mg b.i.d. led to 40% of patients below the minimum effective concentration while a dose of 1200 mg b.i.d. will reduce this proportion to 22%

Identification et dosage de la mitragynine dans les cheveux: à propos d'un cas d'un consommateur régulier de substances psychotropes achetées sur le dark web

International audienceKratom is a preparation obtained from the leaves of a tropical tree native to Southeast Asia, Mitragynia speciosa. Mainly ingested orally, kratom is used recreationally for its opioid and psychostimulant effects. Two of the forty alkaloids identified in the plant are responsible for these effects, the mitragynine and the 7-hydroxymitragynine. Kratom can be used to combat fatigue, improve work performance, treat pain and mood disorders. We report here the case of a 27-year-old young man, regular consumer of kratom (20 grams/day) and who occasionally takes cannabis, opiates, synthetic cannabinoids and “G” (GHB/GBL), purchased on the dark web. The man voluntarily sent his hair cut two months after his last intake of JWH-122 to the laboratory, for analysis. The psychoactive substances were extracted from two 1.5 cm long hair segments by liquid-liquid extraction and then analyzed by ultra-high performance liquid chromatography coupled with mass spectrometry (LC-HRMS). Screening was positive and quantification by LC-MS/MS analytically confirmed the presence of mitragynine at amounts of 2235 pg/mg (proximal segment) and 1717 pg/mg (distal segment) as well as JWH-122. This case supports the limited data available in the literature on the usual concentrations of mitragynine found in the hair

Hair testing for 3-fluorofentanyl, furanylfentanyl, methoxyacetylfentanyl, carfentanil, acetylfentanyl and fentanyl by LC–MS/MS after unintentional overdose

International audiencePurpose: To demonstrate the usefulness of hair testing to determine exposure pattern to fentanyls. Methods: A 43-year-old male was found unconscious with respiratory depression 15 min after snorting 3 mg of a powder labeled as butyrylfentanyl. He was discharged from hospital within 2 days without blood or urine testing. Two locks of hair were sampled 1 month (M1 A: 0–2 cm (overdose time frame); B: 2–4 cm; C: 4–6 cm) and 1 year (Y1: A: 0–2 cm; B: 2–4 cm) later to monitor his exposure to drugs of abuse by liquid chromatography–tandem mass spectrometry after liquid-liquid extraction. Results: Hair analysis at M1 showed a repetitive exposure to 3-fluorofentanyl (A/B/C: 150/80/60 pg/mg) with higher concentration in segment A reflecting the overdose period. The non-detection of butyrylfentanyl was consistent with the analysis of the recovered powder identified as 3-fluorofentanyl. Furanylfentanyl (40/20/15 pg/mg) and fentanyl (37/25/3 pg/mg) were also detected in hair. The second hair analysis at Y1 showed the use of three new fentanyls, with probably repetitive exposures to methoxyacetylfentanyl (A/B: 500/600 pg/mg), and single or few exposures to carfentanil (2.5/3 pg/mg) and acetyl fentanyl (1/1 pg/mg). A decreasing exposure to 3-fluorofentanyl (25/80 pg/mg), and increasing consumption of furanylfentanyl (310/500 pg/mg) and fentanyl (620/760 pg/mg) were also observed despite methadone treatment initiation. The patient claimed not consuming three out of the six detected fentanyls. Conclusions: We report single or repetitive exposure to several fentanyls using hair testing. To our knowledge, this is the first demonstration of 3-fluorofentanyl and methoxyacetylfentanyl in hair samples collected from an authentic abuser. © 2019, The Author(s)

Metabolic profiling of deschloro-N-ethyl-ketamine and identification of new target metabolites in urine and hair using human liver microsomes and high-resolution accurate mass spectrometry

International audienceThe aim of this study was to identify new markers of deschloro-N-ethyl-ketamine (O-PCE), a ketamine analogue that has been involved in acute intoxications with severe outcomes including death and whose metabolism has never been studied before. In vitro study after 2-h incubation with pooled human liver microsomes (HLMs) cross-checked by the analysis of urine and hair from a 43-year-old O-PCE user (male) were performed by liquid chromatography–high resolution mass spectrometry (LC-HRMS). Acquired data were processed by the Compound Discoverer® software, and a full metabolic profile of O-PCE was proposed. In total, 15 metabolites were identified, 10 were detected in vitro (HLMs) and confirmed in vivo (urine and/or hair), two were present only in HLMs, and the remaining three metabolites were identified only in biological specimens. While O-PCE was no longer detected in urine, nine metabolites were identified allowing to increase its detection window. In descending order of metabolites abundance, we suggest using 2-en-PCA-N-Glu (34%, first), M3 (16%, second), O-PCA-N-Glu (15.4%, third), OH-O-PCE (15%, fourth) and OH-PCE (11.9%, fifth) as target metabolites to increase the detection window of O-PCE in urine. In hair, nine metabolites were identified. OH-PCA was the major compound (78%) with a relevant metabolite to parent drug ratio (=6) showing its good integration into hair and making it the best marker for long-term monitoring of O-PCE exposure