RESUMEN

BACKGROUND: Triazolam is a typical drug commonly used in the elderly; however, there have been concerns about its adverse events resulting from age-related changes in physiological function and drug interactions with concomitant drugs. Thus, updated information contributing to the appropriate use based on the latest pharmacokinetic and post-marketing surveillance methods is needed. In this study, we evaluated the appropriate use of triazolam in the elderly by integrating real-world data with a modeling and simulation approach. METHODS: The occurrence risk of adverse events in the elderly was evaluated using the spontaneous adverse event reporting regulatory databases from Japan and the United States. Information on drug concentrations and reactions was extracted from previous publications to estimate the threshold for plasma triazolam concentrations that cause adverse events. The pharmacokinetic/pharmacodynamic (PK/PD) model was then constructed, and the dose and administration were evaluated in various situations anticipated in medical practice. RESULTS: Among all prescriptions, 25.4% were prescribed to individuals aged 80 years or above, and 51.8% were for those aged 70 years or above. A majority of cases involved CYP3A-metabolized drug combinations, accounting for 85.6%. Elderly individuals were at a higher risk of developing delirium and fall-fracture. Based on the constructed PK/PD model, the risk of adverse events increased when the plasma concentration of triazolam exceeded the calculated threshold of 0.44 ng/mL at approximately 6 h after administration. Administering 0.125 mg of triazolam, is half the approved dose for the elderly in Japan was deemed appropriate. Moreover, there was a substantial risk of adverse events even at a dosage of 0.0625 mg in combination with a moderate or strong inhibitor of cytochrome P450 3 A. CONCLUSION: Analyzing large-scale databases and existing research publications on PK/PD can practically contribute to optimizing triazolam drug therapy for the elderly in the daily clinical setting.

Asunto(s)

Modelos Biológicos , Triazolam , Humanos , Anciano , Anciano de 80 o más Años , Triazolam/farmacocinética , Triazolam/administración & dosificación , Triazolam/sangre , Triazolam/efectos adversos , Medición de Riesgo/métodos , Femenino , Masculino , Simulación por Computador , Japón , Interacciones Farmacológicas , Persona de Mediana Edad , Estados Unidos

RESUMEN

The microphysiological system (MPS) is a promising tool for predicting drug disposition in humans, although limited information is available on the quantitative assessment of sequential drug metabolism in MPS and its extrapolation to humans. In the present study, we first constructed a mechanism-based pharmacokinetic model for triazolam (TRZ) and its metabolites in the entero-hepatic two-organ MPS, composed of intestinal Caco-2 and hepatic HepaRG cells, and attempted to extrapolate the kinetic information obtained with the MPS to the plasma concentration profiles in humans. In the two-organ MPS and HepaRG single culture systems, TRZ was found to be metabolized into α- and 4-hydroxytriazolam and their respective glucuronides. All these metabolites were almost completely reduced in the presence of a CYP3A inhibitor, itraconazole, confirming sequential phase I and II metabolism. Both pharmacokinetic model-dependent and -independent analyses were performed, providing consistent results regarding the metabolic activity of TRZ: clearance of glucuronidation metabolites in the two-organ MPS was higher than that in the single culture system. The plasma concentration profile of TRZ and its two hydroxy metabolites in humans was quantitatively simulated based on the pharmacokinetic model, by incorporating several scaling factors representing quantitative gaps between the MPS and humans. Thus, the present study provided the first quantitative extrapolation of sequential drug metabolism in humans by combining MPS and pharmacokinetic modeling.

Asunto(s)

Dispositivos Laboratorio en un Chip , Hígado/metabolismo , Técnicas Analíticas Microfluídicas , Triazolam/metabolismo , Células CACO-2 , Humanos , Cinética , Hígado/patología , Técnicas Analíticas Microfluídicas/instrumentación , Modelos Biológicos , Triazolam/sangre , Triazolam/farmacocinética , Células Tumorales Cultivadas

RESUMEN

Flualprazolam is a novel designer benzodiazepine, structurally related to alprazolam, flubromazolam and triazolam. In the last couple of years, it has been frequently detected in seizures and in forensic cases in Sweden and Finland. However, there is a lack of published blood concentrations for the drug, which presents difficulties when assessing its relevance for the cause of death. A quantitative method for the determination of flualprazolam in post-mortem blood was developed and validated, and subsequently used to analyse samples from 33 deaths previously screened as testing positive for flualprazolam in Sweden and Finland. Most of the cases in the study were accidental deaths (61 %) or suicides (18 %). The median (range) flualprazolam concentration was 18.0 (3.0-68) ng/g. The majority of the deceased were male (82 %) and the median age was 30 years. The median age in the Swedish cases was significantly higher (35 years) than in the Finnish cases (23 years) (p< 0.05). Poly-drug use and particularly the concomitant use of flualprazolam and opioids were very common in the study population. Most of the cases that were positive for flualprazolam were fatal poisonings by a drug (N=23), and in 13 cases, flualprazolam was implicated in the cause of death. Combining the resources of two countries in which all post-mortem toxicology is centralised provided a more comprehensive insight into the toxicology of flualprazolam. Research on novel psychoactive substances, such as flualprazolam, is required in order to be able to provide scientific evidence on the risks of these new substances for drug administration and potential users.

Asunto(s)

Benzodiazepinas/sangre , Drogas de Diseño/análisis , Psicotrópicos/sangre , Triazolam/sangre , Accidentes/mortalidad , Adolescente , Adulto , Distribución por Edad , Anciano , Benzodiazepinas/envenenamiento , Drogas de Diseño/química , Drogas de Diseño/envenenamiento , Femenino , Finlandia/epidemiología , Toxicología Forense , Cromatografía de Gases y Espectrometría de Masas , Humanos , Masculino , Persona de Mediana Edad , Estructura Molecular , Psicotrópicos/química , Psicotrópicos/envenenamiento , Distribución por Sexo , Trastornos Relacionados con Sustancias/mortalidad , Suicidio/estadística & datos numéricos , Suecia/epidemiología , Triazolam/envenenamiento , Adulto Joven

RESUMEN

CYP3A probe drugs such as midazolam and endogenous markers, and plasma 4ß-hydroxycholesterol (4ß-OHC) and urinary 6ß-hydroxycortisol-to-cortisol ratios (6ß-OHC/C) have been used as markers of CYP3A induction in cynomolgus monkeys, as with humans. However, there is limited information on their sensitivity and ability to detect CYP3A induction, as most studies were evaluated only at a high dose of the inducer, rifampicin (RIF; 20 mg/kg). In the present study, the CYP3A induction by RIF over a range doses of 0.2, 2 and 20 mg/kg (n = 4) was examined using CYP3A probe drugs (midazolam, triazolam and alprazolam) and the plasma and urinary endogenous CYP3A markers (4ß-OHC and 6ß-OHC/C). The sensitivity and relationship for detecting CYP3A induction was compared among the markers. Four days repeated oral administration of rifampicin to cynomolgus monkeys reduced the area under the plasma concentration-time curve of all CYP3A probe drugs in a rifampicin dose-dependent manner. Although the endogenous CYP3A markers (4ß-OHC and 6ß-OHC/C) were also changed for the middle (2 mg/kg) and high (20 mg/kg) doses of rifampicin, the fold-changes were relatively small, and CYP3A induction could not be detected at the lowest dose of rifampicin (0.2 mg/kg). In conclusion, CYP3A probe drugs are more sensitive for detecting CYP3A induction than endogenous CYP3A markers in cynomolgus monkeys, even for a short experimental period.

Asunto(s)

Alprazolam/farmacología , Inductores del Citocromo P-450 CYP3A/farmacología , Citocromo P-450 CYP3A/biosíntesis , Midazolam/farmacología , Rifampin/farmacología , Triazolam/farmacología , Alprazolam/sangre , Animales , Área Bajo la Curva , Biomarcadores/sangre , Biomarcadores/orina , Inductores del Citocromo P-450 CYP3A/metabolismo , Relación Dosis-Respuesta a Droga , Interacciones Farmacológicas , Hidrocortisona/análogos & derivados , Hidrocortisona/orina , Hidroxicolesteroles/sangre , Macaca fascicularis , Masculino , Midazolam/sangre , Rifampin/sangre , Triazolam/sangre

RESUMEN

1. To investigate cytochrome P450 3A (CYP3A)-mediated metabolism in vivo, plasma concentrations of triazolam (TRZ) are often monitored as a CYP3A marker in CYP3A-humanised mice. However, it has not been determined whether plasma concentrations of TRZ after intravenous administration can reflect hepatic CYP3A activity in CYP3A-humanised mice. 2. Firstly, we investigated the pharmacokinetics of TRZ in wild-type and Cyp3a-knockout (Cyp3a-KO) mice. Plasma concentration profiles of TRZ and α-hydroxy (OH) TRZ were very similar in wild-type and Cyp3a-KO mice. On the other hand, AUC of 4-OH TRZ in Cyp3a-KO mice was significantly lower than that in wild-type mice. Pregnenolone 16α-carbonitrile (PCN) decreased the areas under the plasma concentration-time curves (AUCs) of TRZ and α-OH TRZ in both groups. There was no significant effect of PCN on AUC of 4-OH TRZ in Cyp3a-KO mice. 3. Next, we verified that AUC of 4-OH TRZ in CYP3A-humanised mice was higher than that in Cyp3a-KO mice, although the difference was not significant. 4. In conclusion, plasma concentrations of 4-OH TRZ, but not those of TRZ and α-OH TRZ, might reflect hepatic CYP3A activity in mice in vivo. These results provide important insights for in vivo studies using a CYP3A-humanised model.

Asunto(s)

Citocromo P-450 CYP3A/metabolismo , Triazolam/farmacocinética , Animales , Área Bajo la Curva , Citocromo P-450 CYP3A/genética , Sistema Enzimático del Citocromo P-450/genética , Sistema Enzimático del Citocromo P-450/metabolismo , Regulación Enzimológica de la Expresión Génica , Humanos , Hígado/efectos de los fármacos , Hígado/metabolismo , Masculino , Ratones Endogámicos ICR , Ratones Noqueados , Microsomas Hepáticos/efectos de los fármacos , Microsomas Hepáticos/metabolismo , Carbonitrilo de Pregnenolona/sangre , Carbonitrilo de Pregnenolona/farmacocinética , Triazolam/sangre , Triazolam/metabolismo

RESUMEN

AIM: The objective of this study was to develop a LC-MS/MS method for the simultaneous determination of triazolam (TRZ) and its two hydroxy metabolites in transgenic mouse dried blood spots (DBS) using BALB/c mouse blood as a surrogate biomatrix. METHODOLOGY/RESULTS: The DBS method involved spotting volume of 10 µl using Ahlstrom 226 sample collection cards. A 'whole spot' analysis (6-mm punch) involved extraction of analytes using water and acetonitrile containing an internal standard. DBS samples were analyzed by a validated LC-MS/MS method with a run time of 4 min. CONCLUSION: This validated LC-MS/MS method using DBS extraction was applied to quantitation of TRZ, α-hydroxytriazolam and 4-hydroxytriazolam in a CYP3A4 transgenic mouse oral pharmacokinetic study of TRZ.

Asunto(s)

Pruebas con Sangre Seca/métodos , Triazolam/sangre , Triazolam/metabolismo , Animales , Cromatografía Liquida , Límite de Detección , Espectrometría de Masas , Ratones , Ratones Endogámicos BALB C , Ratones Transgénicos , Triazolam/farmacocinética

RESUMEN

In recent years, the intake of functional foods containing high-doses of green tea polyphenols (GP) has been increasing. In this study, the long-term safety of high-dose GP was assessed from a pharmacokinetic point of view by focusing on the drug-metabolizing enzyme, cytochrome P450 (CYP). Mice were fed a diet containing 3% GP for 4weeks, and the CYP expression levels and activity were determined. The GP-treated group showed a significant decrease in the hepatic CYP3A and an increase in the hepatic CYP2C expression compared with the control group. CYP1A, CYP2D, and CYP2E expression were not different between the GP-treated and the control groups. In the small intestine, there were no differences in the CYP3A protein levels between the groups. The increase in the plasma triazolam concentration in the GP-treated group was observed. Although no changes were found in the hepatic CYP3A levels in mice receiving a diet containing 0.1% GP for 4weeks, a significant decrease was seen in the hepatic CYP3A level in mice receiving a diet containing 3% GP for only 1week. This study revealed that the intake of a high-dose GP results in a liver-specific decrease in the CYP3A expression level. The results also indicated that the effects of GP on CYP3A were not observed following the intake of a low-dose GP. In the future, caution should be taken in cases when functional foods containing a high-dose GP are concomitantly consumed with a CYP3A substrate drug.

Asunto(s)

Sistema Enzimático del Citocromo P-450/metabolismo , Hígado/efectos de los fármacos , Polifenoles/administración & dosificación , Polifenoles/efectos adversos , Té/efectos adversos , Animales , Citocromo P-450 CYP3A , Intestino Delgado/metabolismo , Masculino , Ratones , Ratones Endogámicos ICR , Triazolam/sangre , Triazolam/farmacología

RESUMEN

We have previously shown that menthol attenuates the anticoagulant effect of warfarin by increasing the expression levels of CYP3A and CYP2C in the liver. This study evaluated the effects of menthol on the pharmacokinetics of the CYP3A substrate triazolam and the CYP2C substrate phenytoin. Menthol was orally administered to mice for 7 d. Twenty-four hours after the administration of menthol, triazolam was orally administered, and the plasma concentration was measured. In addition, the CYP3A metabolic activity for triazolam and the CYP3A expression level in the liver were determined. The effects of menthol on the pharmacokinetics of phenytoin were assessed in the same manner. In the menthol-treated group, the area under the blood concentration-time curve (AUC) of triazolam was lower and its clearance was higher compared with the control group. The CYP3A metabolic activity and CYP3A expression level in the liver were significantly increased in the menthol-treated group compared with the control group. Similarly, the AUC of phenytoin was lower and the hepatic CYP2C expression level was higher in the menthol-treated group. Thus, menthol lowered the plasma concentrations of triazolam and phenytoin when concurrently administered. These effects may be attributed to an increased metabolic activity for these drugs due to the increased expression of CYP3A and CYP2C in the liver.

Asunto(s)

Sistema Enzimático del Citocromo P-450/metabolismo , Interacciones Farmacológicas , Lamiaceae/química , Mentol/farmacología , Fenitoína/farmacocinética , Extractos Vegetales/farmacología , Triazolam/farmacocinética , Animales , Citocromo P-450 CYP3A/metabolismo , Aromatizantes/farmacología , Masculino , Ratones Endogámicos ICR , Fenitoína/sangre , Triazolam/sangre

RESUMEN

The induction of cytochrome P450 enzymes (CYPs) is an important source of drug-drug interaction (DDI) and can result in pronounced changes in pharmacokinetics (PK). Rifampicin (RIF) is a potent inducer of CYP3A4 and also acts as a competitive inhibitor which can partially mask the induction. The objective of this study was to determine a clinical DDI study design for RIF resulting in maximum CYP3A4 induction. A physiologically based pharmacokinetic (PBPK) model was developed to project the dynamics and magnitude of CYP3A4 induction in vivo from in vitro data generated with primary human hepatocytes. The interaction model included both inductive and inhibitory effects of RIF on CYP3A4 in gut and liver and accounting for the observed RIF auto-induction. The model has been verified for 4 CYP3A4 substrates: midazolam, triazolam, alfentanil and nifedipine using plasma concentration data from 20 clinical study designs with intravenous (n=7) and oral (n=13) administrations. Finally, the influence of the time between RIF and substrate administration was explored for the interaction between midazolam and RIF. The model integrating in vitro induction parameters correctly predicted intravenous induction but underestimated oral induction with 30% of simulated concentrations more than 2-fold higher than of observed data. The use of a 1.6-fold higher value for the maximum induction effect (Emax) improved significantly the accuracy and precision of oral induction with 82% of simulated concentrations and all predicted PK parameters within 2-fold of observed data. Our simulations suggested that a concomitant administration of RIF and midazolam resulted in significant competitive inhibition limited to intestinal enzyme. Accordingly, a maximum induction effect could be achieved with a RIF pretreatment of 600 mg/day during 5 days and a substrate administration at least 2 h after the last RIF dose. A period of 2 weeks after RIF removal was found sufficient to allow return to baseline levels of enzyme.

Asunto(s)

Inductores del Citocromo P-450 CYP3A/farmacocinética , Citocromo P-450 CYP3A/metabolismo , Modelos Biológicos , Rifampin/farmacocinética , Alfentanilo/sangre , Alfentanilo/farmacocinética , Células Cultivadas , Inductores del Citocromo P-450 CYP3A/farmacología , Hepatocitos/metabolismo , Humanos , Midazolam/sangre , Midazolam/farmacocinética , Nifedipino/sangre , Nifedipino/farmacocinética , Rifampin/farmacología , Distribución Tisular , Triazolam/sangre , Triazolam/farmacocinética

RESUMEN

Ulcerative colitis (UC) patients may have increased concentrations of drugs in their blood. We hypothesized that this response is mainly due to a decrease in the expression and activity of the drug-metabolizing enzyme, cytochrome P450 (CYP), in the liver. In this study, we have tried to demonstrate the hypothesis. UC was induced in mice by treatment with dextran sulfate sodium (DSS) solution. The mRNA and protein expression levels of CYP, inflammatory cytokine levels, and the metabolic activity of CYP3A in the liver were measured. The nuclear translocations of nuclear factor kappa B (NF-κB), pregnane X receptor (PXR), and constitutive androstane receptor (CAR) were analyzed. The levels of hepatic inflammatory cytokines increased in the DSS-treated group. The hepatic mRNA and protein expression of CYP (CYP1A, CYP2C, CYP2D, CYP2E, and CYP3A) and the CYP3A metabolic activity significantly decreased compared to the control group. Hepatic NF-κB nuclear translocation significantly increased in the DSS-treated group. In contrast, the nuclear translocations of PXR and CAR were decreased. Lipopolysaccharides from inflammatory sites in the colon induce hepatic inflammation in DSS-induced murine colitis. This inflammation then causes an increase in the nuclear translocation of hepatic NF-κB and a decrease in the nuclear translocation of PXR and CAR, resulting in the decreased expression and activities of CYP. The results of this study indicated that at the onset of UC, the decreased activity of hepatic CYP causes an increase in the concentrations of drugs in the blood, leading to an increase in the incidence of adverse reactions.

Asunto(s)

Colitis Ulcerosa/enzimología , Sistema Enzimático del Citocromo P-450/biosíntesis , Sistema Enzimático del Citocromo P-450/metabolismo , Sulfato de Dextran/farmacología , Hepatitis/enzimología , Animales , Núcleo Celular/efectos de los fármacos , Núcleo Celular/metabolismo , Colitis Ulcerosa/complicaciones , Colitis Ulcerosa/inmunología , Receptor de Androstano Constitutivo , Citocinas/metabolismo , Modelos Animales de Enfermedad , Hepatitis/etiología , Hepatitis/inmunología , Masculino , Ratones , Ratones Endogámicos ICR , Microsomas Hepáticos/enzimología , Microsomas Hepáticos/metabolismo , FN-kappa B/metabolismo , Receptor X de Pregnano , Transporte de Proteínas , Receptores Citoplasmáticos y Nucleares/metabolismo , Receptores de Esteroides/metabolismo , Triazolam/sangre , Triazolam/farmacocinética

RESUMEN

A method for the simple and reliable determination of triazolam and midazolam in human plasma using gas chromatography with microelectron capture detection has been developed. Samples (0.5 mL of plasma) were prepared using a simple solvent extraction with 3% isoamyl alcohol/benzene in the presence of NaOH. Two microlitres of the extract were injected onto the capillary column ((5%-phenyl)-methylpolysiloxane). The method was found to be valid in terms of selectivity, linearity, precision, accuracy, and recovery over the concentration range of 0.2 to 20 ng/mL for triazolam, and from 0.5 to 200 ng/mL for midazolam, respectively. Intra- and inter-day precisions determined at three concentrations were from 4.1 to 9.3% for triazolam and from 2.9 to 13.0% for midazolam. The accuracies were within 17.7% for triazolam and within 13.0% for midazolam. This proposed method was successfully applied to a pharmacokinetic study of triazolam or midazolam in healthy volunteers.

Asunto(s)

Cromatografía de Gases/métodos , Midazolam/sangre , Triazolam/sangre , Electrones , Humanos , Solventes/química

RESUMEN

1. To search an appropriate evaluation methodology for the intestinal first-pass metabolism of new drug candidates, grapefruit juice (GFJ)- and vehicle (tap water)-pretreated mice or rats were orally administered midazolam (MDZ) or triazolam (TRZ), and blood levels of the parent compounds and their metabolites were measured by liquid chromatography/MS/MS. A significant effect of GFJ to elevate the blood levels was observed only for TRZ in mice. 2. In vitro experiments using mouse, rat and human intestinal and hepatic microsomal fractions demonstrated that GFJ suppressed the intestinal microsomal oxidation of MDZ and especially TRZ. Substrate inhibition by MDZ caused reduction in 1'-hydroxylation but not 4-hydroxylation in both intestinal and hepatic microsomal fractions. The kinetic profiles of MDZ oxidation and the substrate inhibition in mouse intestinal and hepatic microsomal fractions were very similar to those in human microsomes but were different from those in rat microsomes. Furthermore, MDZ caused mechanism-based inactivation of cytochrome P450 3A-dependent TRZ 1'-hydroxylation in mouse, rat and human intestinal microsomes with similar potencies. 3. These results are useful information in the analysis of data obtained in mouse and rat for the evaluation of first-pass effects of drug candidates to be metabolized by CYP3A enzymes.

Asunto(s)

Citocromo P-450 CYP3A/metabolismo , Midazolam/farmacocinética , Triazolam/farmacocinética , Animales , Bebidas , Citrus paradisi , Interacciones Alimento-Droga , Humanos , Hidroxilación , Cinética , Masculino , Ratones , Ratones Endogámicos BALB C , Microsomas/metabolismo , Midazolam/sangre , Modelos Animales , Oxidorreductasas N-Desmetilantes/metabolismo , Ratas , Ratas Sprague-Dawley , Especificidad de la Especie , Espectrometría de Masas en Tándem , Triazolam/sangre

RESUMEN

OBJECTIVE: The objective of this study was to evaluate the pharmacokinetic and pharmacodynamic interactions between the oral adsorbent AST-120 and triazolam. METHODS: In this randomized, cross-over study, 12 healthy volunteers received a single oral dose of triazolam 0.25 mg alone or with AST-120 2 g given 0, 30 or 60 min before triazolam administration. RESULTS: The area under the plasma triazolam concentration-time curve (AUC(0-∞)) significantly decreased with simultaneous AST-120 + triazolam (alone vs simultaneous: 10.9 ± 6.0 vs 6.4 ± 2.6 ng·h/mL, p = 0.003). Triazolam-induced impairment in psychomotor performance assessed by the digit symbol substitution test was significantly attenuated when AST-120 was administered simultaneously. No significant changes in pharmacokinetic and pharmacodynamic parameters were observed when AST-120 was given 30 or 60 min before triazolam administration. CONCLUSIONS: Administering AST-120 simultaneously with triazolam affects the pharmacokinetics and pharmacodynamics of triazolam. Dosing AST-120 at least 30 min before triazolam administration may avoid these interactions.

Asunto(s)

Carbono/administración & dosificación , Hipnóticos y Sedantes/administración & dosificación , Óxidos/administración & dosificación , Triazolam/administración & dosificación , Adsorción , Adulto , Área Bajo la Curva , Carbono/farmacocinética , Estudios Cruzados , Esquema de Medicación , Interacciones Farmacológicas , Femenino , Humanos , Hipnóticos y Sedantes/sangre , Hipnóticos y Sedantes/farmacocinética , Masculino , Óxidos/farmacocinética , Triazolam/sangre , Triazolam/farmacocinética , Adulto Joven

RESUMEN

A 52-year-old woman was found dead on the floor of the living room on the first floor of a house, which belonged to the man with whom she shared the house. On visiting the site, her clothes were found to be undisturbed. Packages of flunitrazepam (Silece, 2 mg/tablet) and triazolam (Halcion, 0.25 mg/tablet) were found strewn around the victim. Toxicological analysis was performed, and the concentrations of flunitrazepam, triazolam, and their metabolites in the victim's blood and urine were measured by high-performance liquid chromatography coupled with photodiode array and mass spectrometry. A high blood concentration of 7-aminoflunitrazepam was detected (1,270 ng/g), and further metabolites such as 7-acetamidoflunitrazepam, 7-acetamidodesmethylflunitrazepam, and 7-aminodesmethylflunitrazepam were detected in the blood and urine samples. In addition, 4-hydroxytriazolam and α-hydroxytriazolam were detected in her urine at a concentration of 950 and 12,100 ng/mL, respectively.On the basis of the autopsy findings and toxicology results of high concentrations of both flunitrazepam and triazolam derivatives, the cause of death was determined to be acute intoxication from flunitrazepam and triazolam.

Asunto(s)

Ansiolíticos/envenenamiento , Flunitrazepam/análogos & derivados , Flunitrazepam/envenenamiento , Triazolam/análogos & derivados , Triazolam/envenenamiento , Ansiolíticos/sangre , Ansiolíticos/orina , Cromatografía Líquida de Alta Presión , Sobredosis de Droga , Femenino , Flunitrazepam/sangre , Flunitrazepam/orina , Toxicología Forense , Humanos , Espectrometría de Masas , Persona de Mediana Edad , Triazolam/análisis , Triazolam/sangre , Triazolam/orina

RESUMEN

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.

Asunto(s)

Benzodiazepinas/sangre , Benzodiazepinas/orina , Cromatografía de Gases y Espectrometría de Masas/métodos , Alprazolam/análogos & derivados , Alprazolam/sangre , Alprazolam/química , Alprazolam/orina , Benzodiazepinas/química , Diazepam/sangre , Diazepam/química , Diazepam/orina , Humanos , Lorazepam/sangre , Lorazepam/química , Lorazepam/orina , Nordazepam/sangre , Nordazepam/química , Nordazepam/orina , Oxazepam/sangre , Oxazepam/química , Oxazepam/orina , Extracción en Fase Sólida , Triazolam/análogos & derivados , Triazolam/sangre , Triazolam/química , Triazolam/orina

RESUMEN

We describe a single method for the detection and quantitation of 13 commonly prescribed benzodiazepines and metabolites: alpha-hydroxyalprazolam, alpha-hydroxyethylflurazepam, alpha-hydroxytriazolam, alprazolam, desalkylflurazepam, diazepam, lorazepam, midazolam, nordiazepam, oxazepam, temazepam, clonazepam and 7-aminoclonazepam in urine, serum, plasma, and meconium. The urine and meconium specimens undergo enzyme hydrolysis to convert the compounds of interest to their free form. All specimens are prepared for analysis using solid-phase extraction (SPE), analyzed using liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS), and quantified using a three-point calibration curve. Deuterated analogs of all 13 analytes are included as internal standards. The instrument is operated in multiple reaction-monitoring (MRM) mode with an electrospray ionization (ESI) source in positive ionization mode. Urine and meconium specimens have matrix-matched calibrators and controls. The serum and plasma specimens are quantified using the urine calibrators but employing plasma-based controls. Oxazepam glucuronide is used as a hydrolysis control.

Asunto(s)

Benzodiazepinas/sangre , Benzodiazepinas/orina , Cromatografía Liquida/métodos , Meconio/química , Espectrometría de Masas en Tándem/métodos , Alprazolam/análogos & derivados , Alprazolam/sangre , Alprazolam/orina , Clonazepam/análogos & derivados , Clonazepam/sangre , Clonazepam/orina , Flurazepam/análogos & derivados , Flurazepam/sangre , Flurazepam/orina , Humanos , Recién Nacido , Nordazepam/sangre , Nordazepam/orina , Oxazepam/sangre , Oxazepam/orina , Reproducibilidad de los Resultados , Extracción en Fase Sólida , Espectrometría de Masa por Ionización de Electrospray , Triazolam/análogos & derivados , Triazolam/sangre , Triazolam/orina

RESUMEN

A sensitive and selective liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the determination of triazolam and its metabolites, alpha-hydroxytriazolam (alpha-OHTRZ) and 4-hydroxytriazolam (4-OHTRZ), was developed and validated. Triazolam-D4 was used as the internal standard (IS). This analysis was carried out on a Thermo C(18) column and the mobile phase was composed of acetonitrile:H(2)O:formic acid (35:65:0.2, v/v/v). Detection was performed on a triple-quadrupole tandem mass spectrometer using positive ion mode electrospray ionization (ESI) and quantification was performed by multiple reaction monitoring (MRM) mode. The MS/MS ion transitions monitored were m/z 343.1-->308.3, 359.0-->308.3, 359.0-->111.2 and 347.0-->312.0 for triazolam, alpha-OHTRZ, 4-OHTRZ and triazolam-D4, respectively. LLOQ of the analytical method was 0.05 ng/mL for triazolam and 0.1 ng/mL for alpha-OHTRZ and 4-OHTRZ. The within- and between-run precisions were less than 15.26% and accuracy was -8.08% to 13.33%. The method proved to be accurate and specific, and was applied to the pharmacokinetic study of triazolam in healthy Chinese volunteers.

Asunto(s)

Ansiolíticos/sangre , Cromatografía Líquida de Alta Presión/métodos , Espectrometría de Masas en Tándem/métodos , Triazolam/sangre , Ansiolíticos/farmacocinética , Humanos , Estándares de Referencia , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Triazolam/farmacocinética

RESUMEN

The AGD acknowledges that dentists may need an additional permit to perform the procedure described in this article. Many states require dental practitioners to have additional or advanced training in order to perform enteral sedation. In some states, practitioners must have an i.v./conscious sedation permit before they are allowed to titrate (dose) oral medication. The ADA does not believe that oral medication can be titrated (dosed) without an i.v. sedation license. The AGD has adopted and published a white paper on sedation issues, which appeared in the September-October 2006 issue of General Dentistry. The AGD encourages continuing education in sedation modalities for general dentists. Oral conscious sedation (OCS) is an increasingly common practice in dentistry and is at the forefront of evolving state regulations. At the center of the OCS controversy is the oral titration of medications. Most medications available for OCS are used in an "off-label" manner and have no determined maximum recommended dosage for that purpose. This article proposes cumulative maximum dosing guidelines for in-office OCS, with an emphasis on triazolam.

Asunto(s)

Anestesia Dental/métodos , Sedación Consciente/métodos , Moduladores del GABA/administración & dosificación , Hipnóticos y Sedantes/administración & dosificación , Triazolam/administración & dosificación , Administración Sublingual , Procedimientos Quirúrgicos Ambulatorios , Peso Corporal , Relación Dosis-Respuesta a Droga , Interacciones Farmacológicas , Moduladores del GABA/sangre , Moduladores del GABA/farmacocinética , Odontología General , Humanos , Hipnóticos y Sedantes/sangre , Hipnóticos y Sedantes/farmacocinética , Dosis Máxima Tolerada , Guías de Práctica Clínica como Asunto , Volumetría , Triazolam/sangre , Triazolam/farmacocinética

RESUMEN

OBJECTIVE: Grapefruit juice (GFJ) inhibits cytochrome P450 (CYP) 3A4 in the gut wall and increases blood concentrations of CYP3A4 substrates by the enhancement of oral bioavailability. The effects of GFJ on two benzodiazepine hypnotics, triazolam (metabolized by CYP3A4) and quazepam (metabolized by CYP3A4 and CYP2C9), were determined in this study. METHODS: The study consisted of four separate trials in which nine healthy subjects were administered 0.25 mg triazolam or 15 mg quazepam, with or without GFJ. Each trial was performed using an open, randomized, cross-over design with an interval of more than 2 weeks between trials. Blood samples were obtained during the 24-h period immediately following the administration of each dose. Pharmacodynamic effects were determined by the digit symbol substitution test (DSST) and utilizing a visual analog scale. RESULTS: GFJ increased the plasma concentrations of both triazolam and quazepam and of the active metabolite of quazepam, 2-oxoquazepam. The area under the curve (AUC)(0-24) of triazolam significantly increased by 96% (p<0.05). The AUC(0-24) of quazepam (+38%) and 2-oxoquazepam (+28%) also increased; however, these increases were not significantly different from those of triazolam. GFJ deteriorated the performance of the subjects in the DSST after the triazolam dose (-11 digits at 2 h after the dose, p<0.05), but not after the quazepam dose. Triazolam and quazepam produced similar sedative-like effects, none of which were enhanced by GFJ. CONCLUSION: These results suggest that the effects of GFJ on the pharmacodynamics of triazolam are greater than those on quazepam. These GFJ-related different effects are partly explained by the fact that triazolam is presystemically metabolized by CYP3A4, while quazepam is presystemically metabolized by CYP3A4 and CYP2C9.

Asunto(s)

Benzodiazepinas/farmacocinética , Bebidas , Citrus paradisi/química , Hipnóticos y Sedantes/farmacocinética , Triazolam/farmacocinética , Adulto , Análisis de Varianza , Área Bajo la Curva , Hidrocarburo de Aril Hidroxilasas/metabolismo , Benzodiazepinas/sangre , Benzodiazepinas/metabolismo , Cromatografía Líquida de Alta Presión , Estudios Cruzados , Citocromo P-450 CYP2C9 , Citocromo P-450 CYP3A , Sistema Enzimático del Citocromo P-450/metabolismo , Relación Dosis-Respuesta a Droga , Interacciones Alimento-Droga , Semivida , Humanos , Hipnóticos y Sedantes/sangre , Hipnóticos y Sedantes/metabolismo , Masculino , Tasa de Depuración Metabólica , Factores de Tiempo , Triazolam/sangre , Triazolam/metabolismo

RESUMEN

Triazolam was analyzed from human plasma samples by high-performance liquid chromatography (HPLC)-tandem mass spectrometry (MS/MS) with an MSpak GF polymer column (50 mm x 4.6 mm i.d., particle size 6 microm), which enabled direct injection of crude biological samples. Separation of triazolam, and lorazepam as the internal standard (IS) was carried out using 10mM ammonium acetate (pH 3.56)-0.1% formic acid and an acetonitrile gradient elution. Both compounds formed base peaks due to [M + H]+ ions by HPLC/ESI-MS, and product ions were produced from each [M + H]+ ion as seen by HPLC-MS/MS. Quantification of triazolam and the IS in plasma samples was made by selective reaction monitoring using each base peak of product ions of HPLC-MS/MS. The recovery range of triazolam spiked into plasma was 86.4-92.7%. The regression equation for triazolam showed excellent linearity in the range of 0.25-20 ng/mL, and the detection limit was 0.1 ng/mL. Intra- and inter-day precisions for triazolam in plasma samples were not greater than 12.4%. Accuracy for the drug was in the range of 88.0-101.4%. Data obtained after oral administration of triazolam in male and female subjects are also presented.

Asunto(s)

Cromatografía Líquida de Alta Presión/métodos , Espectrometría de Masas/métodos , Triazolam/análisis , Triazolam/sangre , Acetonitrilos/química , Administración Oral , Adulto , Química Farmacéutica/métodos , Femenino , Formiatos/química , Humanos , Concentración de Iones de Hidrógeno , Masculino , Modelos Químicos , Análisis de Regresión , Reproducibilidad de los Resultados