Journal of Analytical Toxicology, Vol. 23, July/August 1999

]Case Report

Toxicological Analysis of Sulpiride in a Lethal Poisoning Case

Pok P. Rop*, Marie H. Sournac, Isabelle Elie, Joi~lle Burle, and Monique Fornaris Laboratoire de Police 5cientifique de Marseille, 97, boulevard Camille Flammarion- 13248, Marseilte 04, France

I Abstract

A fatality following ingestion of sulpiride is presented. The drug was identified and quantitated in postmortem blood by gas chromatography-mass spectrometry and high-performance liquid chromatography with diode-array detection. The concentration was 38 pg/mL, which was in excess of 34 times the therapeutic concentration of sulpiride. For other associated drugs, their concentrations were in their therapeutic ranges.

Introduction

Sulpiride (Dogmatil, marketed in France since 1968 by Delagrange Laboratories) is a neuroleptic drug classified as a substituted benzamide (1) and used in treatment of psychosis. The usual daily dose is 200 to 800 mg orally or by intramuscular injection. Substituted benzamides are relatively safe in thera- peutic doses. However, fatal poisoning can occur (2,3). Different chromatographic methods have been reported for determination of sulpiride in biological fluid (4,5). Therapeutic, steady-state plasma concentrations of sulpiride have been reported and ranged from 0.071 to 1.121 I~g/mL (4). Fatal intoxications ifivolving sulpiride have been previously reported (6,7). This report documents blood concentration of sulpiride in a case of death due to sulpiride overdosage.

Case History

A 38-year-old woman had a long history of mental illness for which she was receiving psychiatric medication. She was found dead at home. Eight empty packages of Dogmatil 50 (Sulpiride, 50-mg tablets) equivalent to an amount of 12 g were found in the bedroom of the deceased. Other packages of various pharmaceu- ticals including Tercian 100 (Cyamemazine, 100-mg tablets), Tranxene 50 (Clorazepate dipotassium, 50-rag tablets), and *Author to whom correspondence should be addressed.

Ludiomil 75 (Maprotiline, 75-mg tablets) were also found. An autopsy was performed after the body was discovered. Several tablets of sulpiride were found in the gastric contents. The post- mortem femoral blood was taken for toxicological analysis.

Experimental

Instrumentation Sulpiride was identified at first by gas chromatography-mass

spectrometry (GC-MS). The system was a Hewlett Packard 6890 GC with a 5973 mass selective detector (MSD). The MSD was used in the electronic impact mode. The ionization voltage was 70 eV. The BPX5 capillary column (15 m x 0.2-ram i.d., 0.25-pm coating, S.G.E., Villeneuve Saint Georges, France) was connected to the MSD. Helium flow rate was 1.5 mL/min through the column. The oven temperature program was as f611ows: 70~ held 1 min, increased to 220~ at 15~ increased to 260~ at 5~ and then to 330~ at 25~ The injector and the

Table I. Summary of the Quantitative Results

Analyzed compounds Blood concentration (pg/mL)

Sulpiride 38 Nordiazepam 2 Cyamemazine 0.11 Maprotiline trace

Table II. Summary of Lethal Concentrations of Substituted Benzamides

Blood concentration (pg/mL)

Drug Anterior report* Present report

Sulpiride 38.7 (7) Sultopride 12 (2) Amisulpride 41.7 (10)

* Reference number in parentheses.

38

294 Reproduction (photocopying) of editorial content of this journal is prohibited without publisher's permission.

Journal of Analytical Toxicology, Vo l . 23 , Ju ly /August 1999

detector temperatures were 250~ and 300~ respectively. Sulpiride was then quantitated in blood by high-performance

liquid chromatography using a screening procedure with diode- array detection (HPLC-DAD). The system was performed on a Waters system (Saint Quentin en Yvelines, France) consisting of a 510 pump, a Symmetry column (25 cm x 4.6-mm i.d., 5-pro particle size, ambient temperature), a Rheodyne 7125 20-pL high-pressure loop injector, and a 990 photodiode-array detector monitored at 240 nm. The UV spectrum of the analyzed com- pound was scanned between 200 and 350 nm. The mobile phase consisted of acetonitrile, methanol, and 0.1M ammonium acetate (30:30:40, v/v/v). The flow rate was I mL/min. The UV and mass spectrum libraries were homemade.

Materials and reagents Acetonitrile, methanol, and ammonium acetate were HPLC

grade (Carlo Erba, Italy). Sulpiride and haloperidol (internal standard) were obtained from Sigma (Saint Quentin Fallavier,

France). Toxitube A extraction tubes were from Toxi-Lab (Irvine, CA).

Sample preparation The blood (1 mL) was taken into a 5-mL glass tube. Three

milliliters of distilled water and 20 pL of haloperidol (internal standard) in methanol (0.1 mg/mL) were added. After vortex mixing for I min, the mixture was pipetted into a Toxitube A extraction tube. The tube was gently shaken for 5 rain and cen- trifuged at 2800 rpm for 10 rain. The organic extract was trans- fered into a conic tube and evaporated to dryness. The residue was reconstituted with 100 pL of methanol, and an aliquot of this solution (2 pL for GC-MS analysis and 20 pL for HPLC analysis) was injected into the chromatograph. Sample standards were prepared from the blank blood spiked with increasing concen- trations (0 to 4 pg/mL) of sulpiride and a constant amount of internal standard (2 pg). Sulpiride blood concentration was cal- culated by comparing the peak-height ratio of drug with that of

A

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Figure 1. Chromatograms and spectra of the blood extracts. A, Chromatogram HPLC-DAD analysis of the blank blood spiked with 4 pg/mL of sulpiride. Peak identification: 1, sulpiride (3 rain); 2, halo-peridol/internal standard (8 min). B, Chromatogram HPLC-DAD analysis of the postmortem blood after five dilu- tions: 1, sulpiride; 2, haloperidol (inter- nal standard). C, Corresponding UV spectra (200--350 nm) of sulpiride in the postmortem blood and sulpiride from the library. D, Corresponding mass spectra of sulpiride in postmortem (1) and sulpiride from the library (2) after GC-MS analysis.

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208 226 248 268 288 388 32@ 348

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[ i

2@e 228 248 260 288 3@8 32@ 348

Mave leng~:h 288 - - - 35E n l (2nm)

2emo ~ (11Je4 n~): C:-L'0X l.O (-)

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295

haloperidol (internal standard) against the standard calibration curve.

Results and Discussion

Qualitative analysis of the blood gave a GC-MS pattern consis- tent with sulpiride, cyamemazine, nordiazepam, and maprotiline. For quantitative analysis of sulpiride, the method was linear over range of 0 to 4 pg/mL. The equation of the curve and correlation (r) were as follows: y = 0.62x + 0.0042, r = 0.998 (where y is height of sulpiride/height of internal standard and x = sulpiride concentration in pg/mL). The limit of determination with UV 240 nm was 25 ng/mL. Sulpiride concentration measured in blood was 38 1Jg/mL. A chromatogram and spectra of blood extract for sulpiride are presented in Figure 1. Other associated drugs, cyamemazine, nordiazepam, and maprotiline, were also quanti- tated in blood by the same method with some modifications. For nordiazepam and maprotiline analysis, tetrazepam was used as the internal standard. The UV detection was monitored at 230 nm for nordiazepam and 220 nm for maprotiline. For cyamemazine, a second mobile phase (acetonitrile/0.1M ammonium acetate, 55:45, v/v, 1 mL/min) and the same internal standard (tetraze- pam) were used. The UV detection was monitored at 270 nm. The summary of the quantitative results appears in Table I. The substituted benzamides were considered to be safe in clin-

ical use. Most problems encountered with these drugs relate to their extrapyramidal side effects (8-10). Sulpiride is less likely to cause sedation than other neuroleptics and antimuscarinic effects are minimal. Cardiovascular effects such as hypotension are generally rare, although they can occur with overdosage (9). Therapeutic steady-state plasma concentration for sulpiride was reported to range from 0.071 to 1.121 1Jg/mL when 50-500 mg was taken daily (4). In our case, the postmortem blood concen- tration of sulpiride (38 IJg/mL) was about 34 times as great as the highest therapeutic plasma level. It is similar to a lethal concen- tration reported by Kintz et al. (7). The substituted benzamides most frequently used in France as neuroleptic drugs are sulpiride, sultopride, and amisulpride. Fatalities attributable to these drugs and their blood lethal concentrations have been reported else- where (Table II). For cyamemazine, the therapeutic plasma con- centrations range from 0.05 to 0.4 lJg/mL (11) and the blood lethal concentrations range from 3.55 to 9.8 IJg/mL (11,12). Clorazepate dipotassium is only detectable after parenteral administration. After an oral dose, the drug changes at once into nordiazepam in the acid of the stomach and is absorbed into the body as nordiazepam, which is metabolized at a later stage to oxazepam. The blood was tested for oxazepam, but it was not detected. Blood therapeutic levels of clorazepate dipotassium (as nordiazepam) have been reported to range from 0.1 to 2.6 IJg/mL (13), and toxic levels were greater than 5 pg/mL (13). In our case, blood concentrations of cyamemazine and nordiazepam were 0.11 IJg/mL and 2 IJg/mL, respectively. These two compounds were present in blood only at therapeutic levels. As for maproti- line, only traces of the drug were detected in blood. A test for ethyl alcohol in the blood was negative. It is certain that only sulpiride is the major factor in this fatality. Concerning sulpiride metabo-

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Journal of Analytical Toxicology, Vol. 23, July/August 1999

lites, Sugnaux and Benakis (14), who worked on the metabolism of the drug, found that the drug is excreted in the urine chiefly as unchanged drug or as oxide metabolite. Up until now, no infor- mation has been available about the quantitation or the pharma- cological activity of any metabolite. Because of the lack of information and standard metabolites, our study was limited to the unchanged drug.

Conclusions

The present report is the first case that we have encountered that documents postmortem blood concentration of sulpiride after poisoning with sulpiride.

Acknowledgment

The authors wish to thank Mr. Vincent Bertolini for his technical assistance.

References

1. P. Jener and C.D. Marsden. Substituted benzamide drugs as selective neuroleptic agent. Neuropharmacol. 20: ] 285-1289 (1981 ).

2. L. Montaz, N. Varache, P. Harry, C. Aymes, A. Turcant, F. Dellile, D. Simonin, and C. Hass. Torsades de pointes Iors d'une intoxication par sultopride. J. Toxicol. Clin. Exp. 12:481-486 (] 992).

3. M. Segerberg-Konttinen, E. Vuori, I. Lukkari, and A. Peuttila. A fatal intoxication by remoximide. J. Forensic Sci. 34:500-503 (1989).

4. H. Tokugana, K. Kudo, N. Jitsufuchi, Y. Ohtsuka, and T. Jmamura. Sensitive determination of sulpiride in human plasma by high perfor- mance liquid chromatography. J. Chromatogr. 691 : 203-207 (1997).

5. J. Bron, A.J. Wittebrood, A.P. deJong, and W.M du Ch,~tinier. Chromatography of substituted benzamide. J. Pharm. Belgium 42: 47-52 (1987).

6. A.D. Duffield and A.V. Kemmenoe. A fatality involving theophylline and sulpiride. TIAFT Bull. 20(3): 9-12 (1990).

7. P. Kintz, A. Tracqui, X. Parent, E. Hanser, and P. Mangin. Fatal sulpiride intoxication. TIAFT Bull. 24(4): 37-39 (1994).

8. M. Gaultier and J.P. Frejaville. A propos de 20 surdosages en sulpiride. J. Eur. Toxicol. Hyg. Environ. 6:42-44 (1973).

9. P. Corvol, F. Bicheliches, and J.M. Alexandre. Pouss~es hypertensives d~clench~es par le sulpiride. Sern. Hop. 50:1265-1269 (1974).

10. A. Tracqui, C. Mutter-Schmidt, P. Kintz, C. Berton, and P. Mangin. Amisulpride poisoning: a report on two cases. Hum. Exp. Toxicol. 14:294-298 (1995).

11. A. Tracqui, P. Kintz, C. Jamey, and P. Mangin. Toxicological data in a fatality involving cyamemazine. J. Anal. Toxicol. 17:386-388 (1993).

12. R. Darmanaden and J.P. Santoro. Intoxication mortelle par cyamemazine. J. Pharm. Clin. 11:306-308 (1992).

13. C.L. Winek. Drug and chemical blood level data 1994. Fisher Scientific publishers, Pittsburgh, PA, 1994.

14. F.R. Sugnaux and A. Benakis. Metabolism of sulpiride: determination of the chemical structure of its metabolites in rat, dog and man. Eur. J. Metab. Pharmacokinet. 4:235-248 (1978).

Manuscript received July 27, 1998; revision received November 2, 1998.