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Identification and Quantification of 22 Benzodiazepines in Postmortem Fluids and Tissues Using UPLC/MS/MS

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Identification and Quantification of 22 Benzodiazepines in Postmortem Fluids and Tissues Using UPLC/MS/MS DOT/FAA/AM-18/1 Office of Aerospace Medicine Washington, DC 20591 Identification and Quantification of 22 Benzodiazepines in Postmortem Fluids and Tissues using UPLC/MS/MS Michael K. Angier Sunday R. Saenz Roxane M. Ritter Russell J. Lewis May 2018 Final Report NOTICE This document is disseminated under the sponsorship of the U.S. Department of Transportation in the interest of information exchange. The United States Government assumes no liability for the contents thereof. ___________ This publication and all Office of Aerospace Medicine technical reports are available in full-text from the Civil Aerospace Medical Institute’s publications website: http://www.faa.gov/go/oamtechreports Technical Report Documentation Page 1. Report No. 2. Government Accession No. 3. Recipient's Catalog No. DOT/FAA/AM-18/1 4. Title and Subtitle 5. Report Date Identification and Quantification of 22 Benzodiazepines in Postmortem May 2018 Fluids and Tissues using UPLC/MS/MS 6. Performing Organization Code 7. Author(s) 8. Performing Organization Report No. Angier MK, Saenz SR, Ritter RM, and Lewis RJ 9. Performing Organization Name and Address 10. Work Unit No. (TRAIS) FAA Civil Aerospace Medical Institute P.O. Box 25082 11. Contract or Grant No. Oklahoma City, OK 73125 12. Sponsoring Agency name and Address 13. Type of Report and Period Covered Office of Aerospace Medicine Federal Aviation Administration 800 Independence Ave., S.W. Washington, DC 20591 14. Sponsoring Agency Code 15. Supplemental Notes 16. Abstract Benzodiazepines, a class of drugs known to cause central nervous system depression, are widely prescribed for a variety of different medical conditions such as anxiety, insomnia, and as a preoperative sedative in conjunction with anesthesia. In fact, four are listed in the top 100 most prescribed drugs. Although there are many medicinal benefits with benzodiazepines, there are many impairing side effects that can impact the ability to safely operate an aircraft. Therefore, the Federal Aviation Administration’s Forensic Toxicology Research Team has developed and validated a comprehensive method for the analysis of 22 benzodiazepines in postmortem fluids and tissues. The newly developed method uses ultra-high performance liquid chromatography-tandem mass spectrometry (UPLC/MS/MS) and a single step “crash-and-shoot” extraction. This new method reduces extraction time, significantly reduces sample volume, and eliminates derivatization steps necessary for commonly employed methods involving solid-phase extraction and GC/MS. For each of the analytes, the linear dynamic range encompasses sub-therapeutic to toxic concentrations. This method proved to be accurate and reproducible with control values not exceeding 20% of the target concentration. Analytes were stable over a 5-day period when stored at 4°C as well as on instrument, post extraction. Additionally, all analytes were stable after three freeze/thaw cycles. Ion suppression was evaluated in a variety of postmortem fluids and tissues. Although there was minimal suppression in fluids, there was suppression observed in tissues. However, this suppression affected the internal standard similarly; therefore, quantitative reliability was maintained. This newly developed UPLC/MS/MS method has been proven to be accurate and precise in the identification and quantification of 22 benzodiazepines in postmortem fluids and tissues. 17. Key Words 18. Distribution Statement Forensic Toxicology, Postmortem, LC/MS/MS, Document is available to the public through the Benzodiazepines Internet: www.faa.gov/go/oamtechreports/ 19. Security Classif. (of this report) 20. Security Classif. (of this page) 21. No. of Pages 22. Price Unclassified Unclassified 19 Form DOT F 1700.7 (8-72) Reproduction of completed page authorized i Contents Introduction ............................................................................................................................................ 1 Materials and Methods ........................................................................................................................... 1 Chemicals and Reagents ..................................................................................................................... 1 Ultra-performance liquid-chromatography-tandem mass spectrometric conditions .......................... 2 Calibration and control preparation .................................................................................................... 3 Sample preparation and extraction method ........................................................................................ 5 Results and Discussion ........................................................................................................................... 5 Conclusion ............................................................................................................................................ 17 References ............................................................................................................................................ 17 ii IDENTIFICATION AND QUANTIFICATION OF 22 BENZODIAZEPINES IN POSTMORTEM FLUIDS AND TISSUES USING UPLC/MS/MS INTRODUCTION Benzodiazepines, a class of drugs known to cause central nervous system depression, are widely prescribed for a variety of different medical conditions including: anxiety, insomnia, convulsion disorders, alcohol withdrawal, and as adjuncts to psychiatric conditions and surgical procedures.(1) While there are many important medicinal uses, benzodiazepines also have the potential for dependence and abuse. There are many impairing side effects such as drowsiness, confusion, dizziness, and lack of coordination.(2,3) Due to the potential impairment associated with these drugs, attempting divided-attention and/or complex activities such as operating a motor vehicle or piloting an aircraft can be especially dangerous. The Federal Aviation Administration (FAA) is concerned with any drugs/pharmaceuticals used by those certified to operate an aircraft. When fatal civil aviation accidents occur, specimens such as blood, urine, liver, kidney, muscle, heart, brain, and other tissues are submitted to the FAA’s Forensic Toxicology Laboratory for analysis. Identification of benzodiazepines and other drugs can provide additional information for accident investigators to aid in their investigations. Over a 10-year period, 2007-2016, 121 cases out of 2582 fatal aviation accidents were found to be positive for one or more benzodiazepines. Since benzodiazepines are some of the most highly prescribed drugs in America, four of these being in the top 100 most prescribed drugs,(4) it is necessary to have an analytical method capable of identifying a majority of benzodiazepines and corresponding metabolites in postmortem fluids and tissues in an efficient manner. There are numerous research articles that describe the analysis of multiple benzodiazepines in blood, urine, serum, and even meconium.(5-9) However, none have been applied to postmortem fluids and tissues. In this paper, we describe a simplified extraction and an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC/MS/MS) separation and quantification method for 22 benzodiazepine compounds in postmortem fluids and tissues. The 22 compounds included in this method encompass all of the benzodiazepines we would expect to encounter in our laboratory. Validation of the method was conducted using the Scientific Working Group for Forensic Toxicology (SWGTOX) guidelines and recommendations.(10) We believe this is the first published method that combines a simple “crash and shoot” extraction with UPLC/MS/MS for the analysis of postmortem fluids and tissues. MATERIALS AND METHODS Chemicals and Reagents Benzodiazepine methanolic standards were purchased from Cerilliant (Cerilliant Corp., Round Rock, TX), Lipomed (Arlesheim, Switzerland), and LGC (Lukenwalde, Germany) at 1.00 mg/mL. Methanolic standards were 7-amino-clonazepam, 7-amino-flunitrazepam, alpha hydroxy-alprazolam, alpha hydroxy-midazolam, alprazolam, bromazepam, chlordiazepoxide, clonazepam, desalkylflurazepam, diazepam, estazolam, flunitrazepam, flurazepam, lorazepam, midazolam, nitrazepam, norchlordiazepoxide, nordiazepam, oxazepam, prazepam, temazepam, and triazolam. Deuterated analogues were purchased from Cerilliant, Lipomed, and LGC at 1.0 mg/mL or 100 μg/mL. The deuterated methanolic standards were 7-amino-clonazepam-d4, 7-amino-flunitrazepam-d7, alpha hydroxy-alprazolam-d5, alpha hydroxy-midazolam-d4, alprazolam-d5, bromazepam-d4, chlordiazepoxide-d5, clonazepam-d4, diazepam-d5, estazolam-d5, flunitrazepam-d3, lorazepam-d4, midazolam-d4, nitrazepam-d5, norchlordiazepoxide-d5, nordiazepam-d5, oxazepam-d5, prazepam-d5, temazepam-d5, desalkylflurazepam-d4, flurazepam-d4, and triazolam-d4. Additionally, lorazepam, oxazepam, and temazepam were purchased as 1 glucuronides at 100 μg/mL from Cerilliant. Helix pomatia (derived β-glucuronidase) was obtained from Sigma Aldrich (Sigma Aldrich, St. Louis, MO). Formic acid, sodium fluoride, LC/MS grade acetonitrile (ACN), isopropanol, and LC/MS grade methanol were purchased from Fisher (Fisher Scientific, Pittsburgh, PA). Double deionized (DI) water was obtained from a Millipore Direct Q-3 UV (Millipore, Continental Water Systems, El Paso, TX). Bovine blood was obtained from Country Home Meat Co. (Country Home Meat Co., Edmond, OK). Immediately upon collection, sodium fluoride and potassium oxalate were added to the blood and mixed to produce a final sodium
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