Bioactivation of the tricyclic antidepressant amitriptyline and its metabolite nortriptyline to arene oxide intermediates in human liver microsomes and recombinant P450s

Amitriptyline, the most widely used tricyclic antidepressant, has been associated with very rare but severe incidences of hepatotoxicity in patients. While the mechanism of idiosyncratic hepatotoxicity remains unknown, it is proposed that metabolic activation of amitriptyline and subsequent covalently binding of reactive metabolites to cellular proteins play a causative role. Studies were initiated to determine whether amitriptyline undergoes cytochrome P450 (P450)-mediated bioactivation in human liver microsomes to electrophilic intermediates. LC/MS/MS analysis of incubations containing amitriptyline and NADPH-supplemented microsomes in the presence of glutathione (GSH) revealed the formation of GSH conjugates derived from the addition of the sulfydryl nucleophile to hydrated metabolites of amitriptyline and nortriptyline, the major N-dealkylated metabolite of amitriptyline. Formation of GSH conjugates was primarily catalyzed by heterologously expressed recombinant CYP2D6, CYP3A4, CYP3A5, and to a less extent, CYP1A2. Corresponding dihydrodiol metabolites of amitriptyline and nortriptyline were also detected by tandem mass spectrometry. These findings are consistent with a bioactivation sequence involving initial P450-catalyzed oxidation of the aromatic nucleus in amitriptyline to an electrophilic arene oxide intermediate, which is subsequently attacked by glutathione and water yielding the sulfydryl conjugate and the dihydrodiol metabolite, respectively. The results from the current investigation constitute the first report on the cytochrome P450-catalyzed bioactivation of the antidepressants amitriptyline and nortriptyline. It is proposed that the arene oxide intermediate(s) may represent a rate-limiting step in the initiation of amitriptyline and nortriptyline-mediated hepatotoxicity.     

Determination of amitriptyline-n-oxide,amitriptyline and nortriptyline in serum and plasma by high-performance liquid chromatography

A method for the determination of amitriptyline-N-oxide, amitriptyline and nortriptyline in serum and plasma has been developed. After extraction from serum or plasma the drugs were analysed by high-performance liquid chromatography.The detection limit was 10 ng/ml (2 ml serum or plasma actually used). The coefficient of variation for all three compounds was below 10%.Amitriptyline-N-oxide was found in rat plasma after an oral dose (10 mg/kg) of amitriptyline-N-oxide.     

Benzodiazepines and Tricyclic Antidepressant Plasma Levels

Twelve patients acted successfully as subjects to study what effect if any the benzodiazepines nitrazepam, diazepam, oxazepam, and chlordiazepoxide might have on steady-state plasma levels of nortriptyline and amitriptyline. No significant detectable effect was discovered. In view of the known interaction effects of other alternative tranquillizing drugs and hypnotics it seems reasonable to choose benzodiazepines wherever possible when anxiolytics or hypnotics need to be added during treatment of depression with tricyclic antidepressants.     

Simultaneous determination of amitriptyline,nortriptyline and four hydroxylated metabolites in serum by capillary gas-liquid chromatography with nitrogen-phosphorus-selective detection

A method for the simultaneous quantification of the antidepressant drug amitriptyline, its demethylated metabolite nortriptyline and four hydroxy metabolites (E-10-hydroxyamitriptyline, Z-10-hydroxyamitriptyline, E-10-hydroxynortriptyline, Z-10-hydroxynortriptyline) in human serum or plasma has been developed. The method is based on a three-step liquid-liquid extraction followed by gas-liquid chromatography (split-splitless injection, HP-5, 25 m×0.2 mm I.D., 0.33 μm capillary) with nitrogen phosphorus-selective detection (GLC-NPD). The limits of detection are 1.5 ng/ml for amitriptyline, nortriptyline, E-10-hydroxyamitriptyline and Z-10-hydroxyamitriptyline and 3 ng/ml for E-10-hydroxynortriptyline and Z-10-hydroxynortriptyline. The within-day and between-day precision is between 6 and 15% at three concentrations (low, moderate and high) for amitriptyline, nortriptyline and E-10-hydroxy metabolites. At low concentrations of 10 ng/ml, the precision of the assay of the Z-10-hydroxy metabolites has been found to be up to 19%. Accuracy is between 91 and 115% for all analytes. The performance of the assay of the hydroxy metabolites is mainly determined by the cleanness and the deactivation of the quartz insert of the injector port. Therefore, every day a freshly cleaned and deactivated insert was used.     

High-performance liquid chromatographic determination of amitriptyline and its main metabolites using a silica column with reversed-phase eluent : Application in mice

A method was developed for the assay of amitriptyline, amitriptyline-N-oxide, nortriptyline, desmethylnortriptyline and E (trans) and Z (cis) isomers of 10-hydroxyamitriptyline and of 10-hydroxynortriptyline in plasma and brain of animals, using high-performance liquid chromatography with ultraviolet detection (254 nm). Single extraction was performed at pH 10.5 from 0.25 ml of plasma or 1 ml of brain mixture. Chromatographic separations were achieved with a silica column and an aqueous methanol mobile phase containing ammonia. This procedure offers high sensitivity (8–10 ng/ml), high linearity (r > 0.99) and acceptable precision (coefficient of variation ≤ 13.3%). The method was used to determine levels of amitriptyline and its major metabolites in mice 30 min after a single intraperitoneal administration of amitriptyline (20 mg/kg).     

Reliable routine method for the determination of plasma amitriptyline and nortriptyline by gas chromatography

A gas chromatographic method has been developed for the determination of amitriptyline and nortriptyline in plasma. OV-17 is used in a 1 m long packed column, with a flame ionization detector and an electronic integrator. Five internal standards are added. The base-specific extraction procedure and the method of calibrating the chromatograph are described in detail. The accuracy, precision and reliability of the method are demonstrated by the results of nearly 700 determinations of each drug, at concentrations ranging from 5 to 400 ng/ml in the plasma. An interlaboratory comparison with a double radioactive isotope derivative assay for nortriptyline has also shown satisfactory agreement.     

Determination of amitriptyline and some of its metabolites in blood by high-pressure liquid chromatography

Conditions for the determination of amitriptyline and some of its metabolites in serum on a reversed-phase material (C-8) by high-pressure liquid chromatography with UV detection at 254 nm were systematically investigated. The separation of tricyclic antidepressants is best carried out on a phase system consisting of C-8 bonded-phase material as the stationary phase and water—methanol—dichloromethane—propylamine as the mobile phase.The precision and detection limit of the method and the extraction efficiency were established. A chromatogram of a serum extract from a patient treated with amitriptyline is shown. Serum levels of amitriptyline and its four main metabolites (nortriptyline, desmethylnortriptyline, trans-10-hydroxy-amitriptyline and trans-10-hydroxy-nortriptyline) in a patient receiving 150 mg of amitriptyline daily, are reported.     

Ocular responses to leukotriene C4 and D4 in the cat

The effects of leukotriene C4 (LTC4) and D4 (LTD4) on the iridial smooth muscles, intraocular pressure, blood-aqueous barrier and regional blood flow in the eye have been studied in cats. The test compounds were injected into the anterior chamber. Both LTC4 and LTD4 caused a dose-dependent constriction of the pupil, the agents being about equipotent. The effect on the iridial sphincter muscle was not dependent on nerve conduction, cyclo-oxygenase products or muscarinic receptors. Maximal constriction was achieved with 0.1-1 microgram of the test compounds. The smallest dose to induce a decrease in pupil diameter was 0.01 microgram. After intracameral injection of 4 micrograms the miotic response was markedly delayed. This indicates that in high concentrations LTC4 and LTD4 probably also stimulate the iridial dilator muscle. The blood flow in the anterior uvea decreased after intracameral injection of 4 micrograms LTC4/LTD4. Smaller doses had no clear effect. There was no effect on the blood-aqueous barrier as judged from the aqueous humor protein concentration. The intraocular pressure decreased slightly after injection of the test compounds.     

Early Rise in Intraocular Pressure after Ammonia Burns

Ammonia is now frequently used in armed robberies by assailants, who possibly misguidedly imagine that it is an easy and safe method of temporarily incapacitating their victim. Nevertheless, two case histories are presented to illustrate the early rise of intraocular pressure which may occur after excessive exposure of the eye to ammonia. The clinical appearance in many respects mimicked that of acute-angle closure glaucoma; the raised intraocular pressure, corneal oedema, and an oval semi-dilated fixed pupil being typical.     

Inhibition of the ocular effects of sodium arachidonate by anti-inflammatory compounds

Topical administration of aqueous solutions of sodium arachidonate to the eyes of rabbits increases intraocular pressure, constricts the pupil and increases both the protein and prostaglandin content of aqueous humor. Arachidonic acid itself dissolved in arachis oil is less effective than sodium arachidonate, although addition of polysorbate mono-oleate greatly increases the effects produced by arachidonic acid. Pretreatment with topically applied non-steroidal anti-inflammatory agents prevents the ocular effects of sodium arachidonate, indomethacin being 2–4 times as potent as either indoxole or pirprofen. Dexamethasone was without effect in these experiments. The results suggested that non-steroidal anti-inflammatory agents deserve serious consideration for topical use in the treatment of ocular inflammation.     

Simplified method for monitoring tricyclic antidepressant therapy using gas—liquid chromatography with nitrogen detection

A simplified gas chromatographic method for the rapid measurement of tricyclic anti-depressant drugs in plasma using a nitrogen-sensitive detector is described. All drugs are extracted and chromatographed under identical conditions. Tertiary amines are separated from their secondary amine metabolites, which are determined simultaneously without the need for derivatisation. The lower limit of accurate determination for most drugs is 10 μg/1.

The method has been applied to the routine measurement of amitriptyline and nortriptyline in plasma from patients receiving antidepressant treatment. Large and important interindividual differences in plasma concentrations in the patients investigated have been found, and the significance of these results is discussed.     

Eye development and the appearance and maintenance of corneal transparency

Embryonic development of the eye, including the cornea, depends on the appearance and steady maintenance of intraocular pressure. The eye is a gravity-sensitive organ, as evidence by changes in pupil diameter during parabolic flight. The cornea is largely a paracrystal of extracellular matrix. The extent to which it will polymerize normally in microgravity has yet to be determined.     

Quantitative analysis of amitriptyline and nortriptyline in human plasma and liver microsomal preparations by high-performance liquid chromatography

A simple, rapid, highly selective and sensitive method for the analysis of amitriptyline and nortriptyline in plasma and human liver microsomes is described. It is suitable for the routine analysis of large numbers of samples using readily available instrumentation and low cost consumables. The detection limit was 2 ng/ml for both compounds and calibration curves were linear over a wide range of concentrations and passed through the origin. The within-batch and between-batch coefficients of variation for amitriptyline and nortriptyline were less than 7.4% and 12.8%, respectively. A series of compounds, including inhibitors used for probing cytochrome P450 activity in vitro, were tested for interference in the assay. Only ketoconazole caused interference and the assay was modified to allow samples containing ketoconazole to be analysed.     

Amitriptyline Prevents N-Methyl-D-Aspartate (NMDA)-Induced Toxicity, Does Not Prevent NMDA-Induced Elevations of Extracellular Glutamate, but Augments Kainate-Induced Elevations of Glutamate

The effect of amitriptyline on kainate- and N-methyl-D-aspartate (NMDA)-induced toxicity and release of amino acids from cerebellar granule neurons was studied. The ED50 for amitriptyline, imipramine, and nortriptyline protection against NMDA-induced toxicity was 6.9, 6.5, and 1.3 microM, respectively. None of these compounds protected against kainate-induced toxicity. Even though amitriptyline was protective against NMDA-induced toxicity, it had no effect on the NMDA-induced increase in extracellular levels of glutamate or aspartate from these cells, indicating a dissociation between NMDA receptor activation (as indicated by glutamate content elevations) and NMDA-induced toxicity. However, kainate and quisqualate treatment resulted in elevations of glutamate and taurine levels that were further augmented in the presence of 25 microM amitriptyline. These findings confirm the reports of others that tricyclic antidepressants have neuroprotective effects related to the NMDA receptor and expand on these reports by showing that even though there is protection against toxicity, the NMDA receptor is nevertheless activated, suggesting an involvement of these compounds at sites removed from the receptor. Furthermore, this is the first report showing an interaction of tricyclic antidepressants with the function of non-NMDA receptors.     

Pronounced inhibition of noradrenaline uptake by 10-hydroxymetabolites of nortriptyline

The potency of the tricyclic antidepressant nortriptyline (NT) relative to that of its major metabolite (E-10-hydroxynortriptyline; E-10-OH-NT) to inhibit the uptake of noradrenaline in rat brain slices incubated in human plasma was 1.75 ± S.D. 0.30. The E- and Z-isomers of 10-OH-NT were equipotent. Hydroxy-metabolites of NT or amitriptyline did not inhibited the neuronal uptake of serotonin.During treatment of 87 patients with NT or amitriptyline the mean ratio between the plasma levels of unconjugated 10-OH-NT and NT was 1.40 ± S.D. 0.86 with a range of 0.32 – 5.0. This ratio increased with age. There was a significant correlation between the plasma levels of the two compounds (r = 0.63; p < 0.001). In three patients treated with NT, the CSF levels of the parent drug and unconjugated 10-OH-NT were similar and about 5 % of the plasma levels.These results indicate that during treatment with NT (or amitriptyline) 10-OH-NT contributes to the effect of these drugs on central noradrenergic neurons. This seems to be of special significance in the elderly.     

Individual differences in effects of tricyclic antidepressants and anticholinergic drugs on operant behavior in the squirrel monkey

Tricyclic antidepressant drugs generally only decrease operant behaviors in most species studied. The present work was prompted by observations that low and moderate doses of certain tricyclic antidepressant drugs markedly increase responding under fixed-interval schedules of reinforcement in some squirrel monkeys. Amitriptyline was the most potent of the drugs studied, and nortriptyline, imipramine, chlorimipramine and desmethylimipramine produced increases at higher doses. There was an excellent correspondence between the effects of amitriptyline and those of atropine in individual subjects. The monkeys showing increases in responding with amitriptyline (0.1 – 10 mg/kg, i.m.) also showed the most marked increases with atropine (0.03 – 1.7 mg/kg, i.m.), and those showing no increases with amitriptyline also showed no increases with atropine (r = 0.95). Inter-individual differences in the effects of acutely administered tricyclic antidepressant drugs may thus be mediated by differential sensitivities of the monkeys to the antimuscarinic properties of these drugs.     

Determination of amitriptyline and nortriptyline in human plasma by quantitative thin-layer chromatography

A thin-layer chromatographic method for simultaneous determination of amitriptyline (AT) and nortriptyline (NT) in human plasma is described. Both substances are extracted from biological material by means of a single extraction. The extract is evaporated until dry and the residue quantitatively applied to a silica gel thin-layer plate. AT and NT are separated from interfering plasma components by chromatography. The spots are visualized by nitration, reduction and coupling with N-(1-naphtyl)ethylenediamine on the plate. The intensity of the azo-dyes formed can be measured densitometrically. Using 1 ml of plasma, the sensitivity limit was 0.5 ng/ml for both substances. About 10–15 plasma samples can be analysed per day. The method is applicable to pharmacokinetic studies after a single oral dose of 25 mg AT as hydrochloride in man.     

Inhibition of acetylcholinesterase from Electrophorus electricus (L.) by tricyclic antidepressants

The effects of tricyclic antidepressants drugs (TCA) amitriptyline, imipramine and nortriptyline, on purified Electrophorus electricus (L.) acetylcholinesterase (AChE; acetylcholine hydrolase, EC 3.1.1.7) were studied using kinetic methods and specific fluorescent probe propidium. The antidepressants inhibited AChE activity by a non-competitive mechanism. Inhibition constants range from 200 to 400 microM. Dimethylated amitriptyline and imipramine were more potent inhibitors than the monomethylated nortriptyline. Fluorescence measurements using bis-quaternary ligand propidium were used to monitor ligand-binding properties of these cationic antidepressants to the AChE peripheral anionic site (PAS). This ligand exhibited an eight-fold fluorescence enhancement upon binding to the peripheral anionic site of AChE from E. electricus (L.) with K(D)=7 x 10(-7)M. It was observed that TCA drugs displaced propidium from the enzyme. On the basis of the displacement experiments antidepressant dissociation constants were determined. Similar values for the inhibition constants suggest that these drugs have similar affinity to the peripheral anionic site. The results also indicate that the catalytic active center of AChE does not participate in the interaction of enzyme with tricyclic antidepressants. These studies suggest that the binding site for tricyclic antidepressants is located at the peripheral anionic site of E. electricus (L.) acetylcholinesterase.     

Inhibition of sparteine oxidation in human liver by tricyclic antidepressants and other drugs

Testing for competitive inhibition of sparteine oxidation in the 9000 × g supernatant fraction from human liver provides an in vitro means to identify drugs which can bind to the same form of cytochrome P450 which oxidizes sparteine. There has so far been only two outcomes of this test: either the drug examined competed with sparteine for a common binding site, or it did not inhibit the reaction. The results of such in vitro testing implicated the involvement of guanoxan, nortriptyline, desipramine, imipramine, amitriptyline and chlorpromazine with this enzyme. Amobarbital, tolbutamide and guanethidine in therapeutic concentrations did not interfere with sparteine oxidation by this preparation.     

Quantification of antidepressants and antipsychotics in human serum by precipitation and ultra high pressure liquid chromatography-tandem mass spectrometry

The present article describes the quantification of mirtazapine, O-desmethylvenlafaxine, quetiapine, venlafaxine, and ziprasidone (group 1), and amitriptyline, citalopram, clomipramine, clozapine, desmethylclomipramine, desipramine, imipramine, and nortriptyline (group 2) in human serum for therapeutic drug monitoring. The method was developed to replace old techniques which applied solid phase extraction and ultra-violet detection. The old methods had reached their limit of capacity regarding the number of samples and co-medicated drugs interfering with the detection. Serum samples were precipitated with zinc sulphate and methanol containing a stable isotope labelled analog for each analyte. Quantitative analysis was performed by ultra high pressure liquid chromatography combined with a tandem mass spectrometer using a Zorbax SB-C8 column (2.0 × 50 mm; 1.8 μm) with a mobile phase consisting of 0.1% formic acid in water and methanol, respectively. The total run time of the chromatography was 4 min. Precision and trueness varied from 2.6% to 14.9% and 87.6% to 103.5%, respectively. At the lower limit of quantification, precision was up to 17.9% and trueness varied from 89.5% to 111.5%. A five point standard curve covering the clinically relevant ranges with a power function fit was applied for calibration. Ion suppression from matrix effects and internal standards were thoroughly investigated and are discussed. Process efficiency rates varied from 42% to 99%. The method has shortened the response time, reduced interference from other drugs, avoided acetonitrile usage, and reduced the amount of serum needed for analysis 50-fold.