Toxicology

Toxicology
-Study of the substances Introduced exogenously into the body.
-.
 Definition of Terms

TOXICOLOGY
Toxicology (from the Greek words - toxicos
"poisonous" and logos) is a branch of Biology,
chemistry, and medicine
Concerned with the study of the adverse effects of
chemicals on living organisms.
It is the study of symptoms, mechanisms, treatments
and detection of poisoning, especially the poisoning
of people.
 Definition of Terms

Therapeutic drug monitoring is a branch of

chemicals that specializes in the measurement of
medications levels in blood.

Its main focus is on drugs with a narrow Therapeutic

ranges, i.e. drugs that can easily be under- or
overdosed.
]
 Definition of Terms

In Pharmacology, many medications are used

without monitoring of blood levels,

as their dosage can generally be varied

according to the clinical response that a
patient gets to that substance.
Indications for therapeutic drug monitoring

Indications for therapeutic drug monitoring

include:
Experimentallydetermined relationship
between plasma drug concentration and
the pharmacological effect.

Knowledgeof the drug level influences

management
Indications for therapeutic drug monitoring

Indications for therapeutic drug monitoring

include:
Narrow w therapeutic window.

Potential patient compliable problems.

The drug dose cannot be optimized by

clinical observation alone.
Common reasons for sub-therapeutic or toxic levels

Sub-therapeutic levels Toxic levels

* Non-compliance * Overdose
Dose too low Dose too high
Malabsorption Dose too frequent
Rapid Metabolism Impaired renal
Function
Reduced Hepatic
metabolism
 Drug Interactions

 Drug
Interference
Inc.
plasma
conc’n

Affected Drug Distribution

Metabolism Excretion
Absorption

Drug Interference Dec

plasma
conc’n
 Drug Actions

1. Replacing or acting substitutes for missing

chemicals
2. Increasing or stimulating certain cellular activities
3. Depressing or slowing cellular activities
4. Interfering with the functions of foreign cells
Factors influencing the Relationships between Drug dosage and the
intensity of its effect”

• Compliance
Drug Prescribed • Correct drug

• Absorption, distribution, metabolism,

Dose taken • Excretion

• Diffusion/ active transport

Plasma
• Protein binding in blood
concentration
Concentration at •
Tissue Responsiveness
the sites of • Effects of other drugs
action
Intensity of • Over or under-dose
effect
 Factors Affecting the body’s Response to a Drug

1. Weight:
2. Age:
3. Gender
4. Physiological factors: Diurnal rhythm of the nervous and
endocrine system, acid-base balance, hydration, and electrolyte
balance.
5. Pathological factors
6. Genetic factors
7. Immunological Factors
8. Environmental factors
9. Tolerance
10. Accumulation
 Terminology in Toxicology

Occupational Toxicology- deals with the

chemicals found in the workplace.
Environmental Toxicology – deals with the
potentiality deleterious impact of chemicals, present
in pollutants of the environment to living organism
 Ecotoxicology- concerns with toxic effects of
chemical and physical agents on living organisms.
Toxicity- ability of a chemical agent to cause injury.
 Areas of Toxicology

1. Detection of Drugs of abuse

2. Monitoring / Therapeutic drug level
3. Detection of Environmental Carcinogens
4. Detection of Toxins or Poisons
 Basic Techniques for Drug detection in Serum and Urine

1. Immunochemical Method

 * Enzyme mediated for (multiplied) immunologic
 techniques
 * Fluorescent polarization

2. Chromatographic Procedures
* Thin layer Chromatography
* High performance Liquid Chromatography
* Gas-chromatography with Mass Spectrometry
 Drugs of Abuse

* Cocaine
* Opium
* Tranquilizers: Benzodiazepines
* Sedatives- Hypnotics: Barbiturates
* Dopaminergic Pathway Stimulants
* Hallucinogens
 Therapeutic Drug Monitoring

1. Cardiotropics
2. Anticonvulsants
3. Antiasthmatics
4. Anti-inflammatory drugs
5. Immunosuppresives
6. Drug used in treating manic –depression
7. Narcoleptics, Antipsychotic and major
tranquilizers
8. Chemotherapeutic agents
 Environmental Carcinogens

1. Benzpyrine
2. Nitrites
3. Aflatoxins
4. Aromatic hydrocarbon
 Toxins and Acute Poisoning

Classification
 * Iron
 * Lead
 * Mercury
 * Cyanide
 * Carbon Monoxide
 * Alcohol
 * Ethylene Glycols
 * Arsenic
 Iron Poisoning

> 4th most common elemnt in nature

> 2nd most abudant metal
> Mechanism of Toxicity
 Toxicity is due mainly to corrosive effects and
 cellular toxicity
 1. Direct corrosive effect on mucosal cell results into
> Fluid loss from GIT – hypovolemia
 > Hemorrhagic necrosis and perforation
 2. Cellular dysfunction resulting into lactic
 acidosis and necrosis.
 Iron Poisoning

common poisoning in
young children by ingestion
of iron containing products
 Iron Poisoning

Diagnosis
 1. History
 2. S/S: Vomitting, bloody diarrhea, hypothermia
 3. Lab. results: WBC = more than15,000/ cmm,
blood glucose : more than 150 mg/dl, Abdominal x-ray-
radio opague pills
Serum Fe determination: If serum Fe level is > 459-500
ug /dl or higher than
Treatment: Chelation therapy using Deferoxamine
 Iron Poisoning

Toxic Dose
 Acute lethal dose in animal studies = 150 mg- 200
mg/kg
 The lowest reported in children = 600 mg
Symptoms of toxicity is unlikely to occur if
greater or equal to 20-30 mg/kg of Fe is ingested
 > 40 mg/kg is considered potentially serious
 > 60 mg/kg is potentially lethal.

 Iron Poisoning

Toxic effects:
-hepatic cell damage, shock, lactic acidosis, vomiting,
severe gastroenteritis, melena, abdominal pain,
hematemesis, systemic toxicity, (cyanosis, convulsions,
coagulopathy, renal and hepatic failure), GI obstructions
or strictures
Treatment:
-emesis, gastric lavage, chelation therapy with
deferoxamine
 Lead Poisoning

* It is widely distributed in the earth crust

* Found in wide variety of products such as
Batteries,
 electronic cable insulator, calculator, pencil,
 paints, pottery, ceramics glass, water lead pipes
* Absorption/ administration
 1. Inhalation
2. Ingestion
3. Dermal absorption
 Lead Poisoning

The largest body compartment od lead

is the bone which contains
approximately 96% of the total body
burden
Half-life: 32 years
 Lead Poisoning

Toxic Effects
CNS symptoms (encephalopathy, convulsion, stupor),
albuminuria, hematuria,
pyuria, anemia (hypochromic, micro/normocytic) with
basophilic stippling,
hyperactive deep tendon reflexes,
intention tremor,
abnormal jaw jerk,
abnormalities of stance and gait
 
 Lead Poisoning

Other toxic effects

disrupts heme synthesis
-increases ALA in urine
-decreases ALAD activity in RBC
-increases free erythrocyte protoporphyrin
-increases zinc protoporphyrin
 Lead Poisoning

Treatment:
Gastric lavage, dilute magnesium sulfate, dilute sodium
sulfate, chelation with dimercaprol, calcium disodium
edatate, succimer
 
 Lead Poisoning

Manifestation
• Acute manifestation are primarily CNS symptoms
and GI.
• Chronic toxicity is more common.
* Bone-target body compartment of lead deposits
• Approximately 96% of total body burden are found
there and the half-life is 32 years.
• Malaise, weight loss, anorexia and constipation-
chronic toxicity
 Lead Poisoning

1. Lead Encephalopathy- manifested by malaise with

apathy, drowsiness, stupor, seizure.
2. Peripheral Neuropathy- wrist drop or foot drop
3. Lead Nephrosis- albuminuria, hematuria, and
pyuria.
4. Hematologic Problem- hypochronic or
normochronic anemia with basophilic stipping
 Lead Poisoning

Serum lead level of > 10 u/dl indicates excessive

lead absorption while concentrations >25 u/dl
indicates consideration of chelation theraphy.
Organo- lead compounds such as ethyl and
tetramethyl lead are lipid soluble and produce their
major toxic effects on CNS.
 Lead encephalopathy occurs early at onset of
intoxication nor correlated with blood lead
concentration
 Laboratory Diagnosis

Whole blood level is the most useful indicator of lead

exposure.
 levels between 10-25 ug/dl- associated with low
IQ and impaired neurobehavioral development in
children exposed in utero or early childhood.
 levels between 60-80 ug/dl –associated with GI
symptoms and subclinical renal efects.
 levels in excess of >80 ug/dl- serious overt
intoxication may occur.
 Encephalopathy and neuropathy are usually associated
with levels >100 ug/dl.
 Laboratory Diagnosis

Lead levels in serum maybe determined directly

using either atomic adsorption spectroscopy or by
anode stripping voltammetry.
Lead excretion increases and decreases more rapidly
in urine than in the blood.
 Normal urinary lead excretion is >50 ug/dl.
 Chelatable lead predominantly reflects lead in soft
tissues which in most cases correlates satisfactory
with blood concentration.
 Diagnostic Principle

Assay for Zn protoporphyrin as simple

fluorometric method is also an excellent
screening test.
Most sensitive screening test for organo lead
poisoning is decreased ALAD activity in urine.
 Treatment

Removal of soluble lead compounds by gastric

lavage.
Use of chelating agent ( Calcium EDTA and
Dimercaprol).
 MERCURY POISONING

Mercury compounds exist in 4 different forms with

different toxicologic potentials:
1. Elemental mercury (Hgº) or metallic mercury
2. Mercurous (Hg+)
3. Mercuric (Hg +2)
4. Alkyl mercury or organomercurials
 -environmental pollutants
 
 Mercury

1/3 of commercially available mercury is used in the

manufacture of caustic soda and chlorine.

Other uses include electrical equipment,

thermometer, other measuring and control
instrument, dental amalgam, pains and pigments,
gold mining.
 Mercury

Others are also found in antiseptic mercurochrome

and thimerosal.

Aquatic organisms can covert inorganic mercury to

methyl mercury with resulting bioacumalation in
large carnivorous fish.
 Mercury

Mechanism of toxicity
 mercury reacts with sulfhydryl groups resulting in
enzyme inhibition and pathologic of cellular membranes.
1. Elemental Mercury- poorly absorbed in the GIT if
mucosal integrity is preserved.
 no toxic effect were noted unless it is converted to
divalent form via oxidation-reduction with water and
chloride.
 Significant poisoning occur when it is inhaled or
absorbed through skin.
 Mercury

2. Inorganic Salts of Mercury- mercurous salt (HG+) is

poorly soluble thus it is poorly absorbed.
 Mercuric salt is readily soluble and readily absorbed
after oral ingestion or inhalation.
 manifestation include severe inflammation of the
mouth as well as other GI symptoms.
 Kidneys are the preferred sites of accumulation
causing acute renal tubular and glomerular injuries
 Both are excreted mainly in the urine.
 Mercury

3. Organic Mercury Compounds- contain alkyl, aryl,

and alkoxyalkyl moieties.
 These are environmental pollutants containing at
least one covalent mercury carbon bond.
 The alkoxyalkyl and aryl containing mercury
compound undergo metabolic breakdown and
biotransformation to produce inorganic mercury
compounds.
 Alkyl forms are more lipid soluble and passes readily
through the biological membranes on ingestion
 It generally has greater absorption in the body.
 Major clinical effect is in the CNS with a biological half-
life of 70-90 days.
 Major route of excretion is bile.
 Methyl mercury can be reabsorbed via the
enterohepatic circulation accounting for its extended
half-life.
 Organic and elemental mercury causes CNS effect. GI
symptomalogy are primarily seen with inorganic salts
and elemental mercury produces mainly pulmonary
reactions.
Toxic effects:
-Systemic toxicity, local skin and mucous membrane
lesion, severe pulmonary reaction
 
Hair analysis
-helps in identifying chronic mercury exposure
 
 Treatment

Gastric lavage, emesis and use of dimercaprol.

However, dimercaprol should not be used in
poisoning caused by methyl and alkyl containing
mercury because it increases their concentrations.

 ORGANOPHOSPHATES AND CARBAMATES

ORGANOPHOSPHATES CARBAMATES

Esters of phosphoric Synthetic derivatives of

acid or thiophosphoric carbamic acid
acid
 ORGANOPHOSPHATES AND CARBAMATES

Both are widely used as pesticides in agriculture.

Interfere with neurotramsmission inhibiting the
enzyme acetylcholinesterase
Rapidly absorbed by inhalation and ingestion
through the skin.
 Toxic dose

Degree of intoxication is affected by:

a) Rate of exposure
b) Ongoing metabolic degradation and elimination of
organophosphate
c) Rate of metabolism to its more toxic derivative
 Laboratory diagnosis

Measurement of erythrocyte acetyl cholonesterase

Plasma pseudocholinesterase activities-more
sensitive
 Toxic Dose

Levels 30-50% of normal is considered exposure but

more than 50% inhibition would lead to toxic
manifestation.
Confirmation of poisoning rather than diagnosis by
laboratory determination.
Sequential post-exposure cholinesterase
determination-best way to confirm organophosphate
poisoning
 Treatment

1. Respiratory support if necessary

2. Decontamination
3. Gastric lavage or emesis
4. Observe patient at least 6-8 hours to rule out
delayed onset symptoms.
 Specific drugs and antidotes

1. Atropine- antimuscarinic agent. Most clinically

important indication to continued atropine
administration is persisted wheezing and
bronchorhea
2. Pralidoxime- specific antidote that acts to
regfenerate enzyme activity at all affected sites.
 Laboratory diagnosis of carbamates

Rbc cholinesterase and plasma pseudocholinesterase

are not reliable indicators of carbamate poisoning
because enzyme activity rapidly recovers within
several minutes to hours+ thus normal level do not
rule out intoxication.
ALCOHOLS
 Ethanol

Most common drug of abuse

Commercial liquors, colognes, perfumes, aftershave,
mouthwash, rubbing alcohol, food flavoring,
pharmaceutical preparations on the form of elixir.
 consumed in less than 1 hour
Toxic effects:
-decreased inhibition, in coordination, blurred vision,
slurred speech, stupor, coma, seizures, death
 Note; capillary and arterial blood samples most
accurately reflect brain ethanol concentration
 Toxic dose

Fatal dose is 300-400 ml of pure ethanol (600-800

ml of 100 proof whisky) consumed in less than one
hour.
Metabolism:
-hepatic alcohol dehydrogenase---acetaldehyde+acetic
acid---Kreb’s cycle---carbon dioxide+water
Lethal dose: 300-400 ml pure ethanol
 600-800ml of 100 proof whiskey
 Ethanol

Mechanism of toxicity:
1. CNS depression-principal effect of acute
intoxication
2. Hypoglycemia- due to impaired gluconeogenesis in
patients with depleted glycogen stores
3. Trauma- predisposes individuals to trauma due to
impaired mental status and impaired judgment
 Clinical presentation

A. Acute Intoxication

B. Chronic Ethanol Abuse
C. Alcohol withdrawal
 Diagnosis

Ethanol intoxication- history of ingestion

• Characteristic smell of fresh

alcohol and fetid odor
• Symptoms of nystagmus,
ataxia and altered mental
status
 Treatment

Acute intoxication- protect airway to prevent

aspiration
Give glucose and thiamine
Treat coma and seizure
Correct hypothermia
Most recover in 4-6 hours
Alcohol withdrawal- benzodiazepines or
phenobarbital
 Methanol Poisoning

Occurs in patients who ingest methylated spirits or

methanol-containing antifreeze
Metabolism:
-liver: methanol---(alcohol dehydrogenase)---
formaldehyde+formic acid (ocular toxicity)
Toxic effects:
-diminished light sensation or frank blindness
 Isopropyl Poisoning

Half-life: 3 hours
Metabolism: in liver: isopropanol---(alcohol
dehydrogenase)---acetone+carbondioxide+water
Lethal dose: 250 ml
Toxic effects;
-CNS depression, nausea, vomiting, hematemesis,
melena, abdominal pain, gastritis, confusion, coma,
hypertension, respiratory failure
Treatment:
-activated charcoal with gastric lavage, hemodiualysis
 
 ETHYLENE GLYCOL AND OTHER GLYCOLS

Ethylene glycol is the primary ingredients in

antifreeze. Alcoholics sometimes consume it as an
alcohol substitute.
 ETHYLENE GLYCOL AND OTHER GLYCOLS

Mechanism of toxicity
A. Ethylene glycol- metabolized by alcohol
dehydrogenase to glyaldehyde which is
metabolized to glycolic acid, glyoxylic and oxalic
acids.
B. Other glycols- propylene glycol and butylene
glycols are relative low toxicity and polypropylene
glycol is non-toxic.
 Toxic dose

Approx. lethal dose of 95 % ethylene glycol is 1.5

ml/kg.
Fatal dose of ethylene glycol is around 100 mg.
 Clinical presentation

Anuria and necrosis are the principal symptoms of

acute poisoning
 Diagnosis

a) History of ingestion
b) Typical syptom
c) High osmolar and anion gap
d) Oxalate and hippurate crystals which may be seen
in urine
e) Since most antifreeze products also contain
fluorescein, the urine may fluoresce under wood’s
lamp
 Treatment

Administer ethanol
Administration of pyridoxine, folate and thaimine
cofactors required for the metabolism of ethylene
glycol that may decrease toxicity by enhancing
metabolism of glyoxilic acid to its non-toxic
metabolites.
Environmental Carcinogen
TOXINS AND ACUTE POISONING
ENVIRONMENTAL CARCINOGEN
-chemical agents in the environment which
predispose individuals exposed to develop
tumors in various tissues where these agents
accumulate

 
 Environmental Carcinogen

1. Nitrites- used as preservatives in red meat causing

colon cancer.
2. Benzpyrenes- aromatic compound produced in
cigarettes & also in the exhaust of engines,
3. Aflatoxins- produced by fungus Aspergillus
causing hepatic carcinoma
4. Benzene and ionizing radiation- causes acute
leukemias
5. Vinyl chloride and thorotrast- used as dyes and
causes angiosarcoma
TOXINS AND ACUTE POISONING

Example:
Benzpyrene
-aromatic compound in cigarettes, exhaust of
engines
-cause lung cancer
Nitrites
-preservatives in red meat
-cause colon cancer
Benzidine dyes, Beta-napthylamine, and
Dimethylbenzanthracene
-causes multiple malignancies
Aflatoxin
-produced by fungus Aspergillus
-causes hepatocellular carcinoma
Benzene (Hydrocarbons) and ionizing radiation
-causes leukemia
Vinyl chloride and Thonotrast (dye)
-causes angiosarcoma
 Asbestos
-lung cancer and mesothelioma
Polychlorinated biphenyls (PCB) and dioxin
-variety of cancers
Note:
Most are inactive in their native
forms but are transformed into
carcinogens through oxidative
reactions catalyzed by
cytochrome P450 dependent
systems.
 CYANIDE POISONING

 This is highly reactive chemical with variety of uses

including chemical synthesis, laboratory analysis and
metal platings.

 Common route of exposure is through inhalation of

smoke produced by burning plastics (producing
hydrogen cyanide) and paints.
.
 CYANIDE POISONING

 Other sources are the cassava, fruit seed (apricot

and cherries) and drugs as in nitroprusside.

 Salts of cyanide have been used in suicide and

homicide poisoning attempts.
 Cyanide

Mechanism of toxicity
1. Cyanide binds to ferric iron ( Fe+3)- forming a
relatively stable cyanoferric complex.
 This prevents reduction of ferric to ferrous ion in
the cytochrome oxidase electron transport system
inhibiting the production of ATP and forcing the cell
to produce energy via anaerobic metabolosm.
 Cyanide

Mechanism of toxicity
.
2. Although cyanide binds preferentially to ferric form,
it also binds to ferrous Fe in the Hgb producing
cyanohemoglobin which cannot transport oxygen.
Cyanide
-cyanide anion binds
avidly to iron in the ferric
or trivalent state
-able to inactivate iron-
containing enzymes that
cycle between ferrous and
ferric states in redox
reactions
Cyanide
produces tissue and cellular
hypoxia (inhibits the electron
transport system and prevents
cellular respiration and ATP
formation)
-prevents utilization of oxygen and
aerobic metabolism producing
severe metabolic (lactic) acidosis
 Toxic dose:

1. Exposure to hydrogen cyanide gas (HCN) at low

levels (150-200ppm) can be rapidly fatal.
Permissible exposure limit to HCN is 10 ppm.
2. Adult ingestion of as little as 200 mg of Na or K
salts may also be fatal.
Cyanide
- 

Symptoms of cyanide overdose:

Tachypnea, respiratory depression
and cyanosis, hypotension,
convulsion, and coma, death
occurs in a matter of minutes
because cyanide is a fast acting
toxin
 
 
 Manifestations

 Victims of cyanide poisoning show symptoms of

hypoxia, as in CO poisoning.

 Cyanide poisoning affect organs with large oxygen

consumption.

 Respiratory depression, cyanosis, hypotension,

convulsion and coma.
 Manifestations

 Death may also occur in a matter of minutes because

cyanide is fast acting toxin.

 The clue to the diagnosis is the bitter almond odor

of the breath altered mental status,
tachypnea in the absence of cyanosis and
unexplained metabolic acidosis.
 CYANIDE -DIAGNOSIS

Diagnosis/signs:

Odor of bitter almonds in patient

mouth,
occurrence of altered mental status
and
tachypnea, in the absence of cyanosis
---unexplained metabolic acidosis
 
 Treatment

Antidotal therapy is based on a 2-step strategy:

First pull the cyanide ion away from cytochrome A3.

Hgb is converted to methemoglobin using specific oxidants ( amyl

nitrite and Na nitrite) via inhalation.

Methemoglobin directly competes with ferricytochrome A3 to

form methmoglobin cyanide complex which relatively non-toxic.
 Treatment

Antidotal therapy is based on a 2-step strategy:

Second: Na thiosulfate is given IV which

reacts with cyanomthemoglobin to form thiocyante
which is also harmless and excreted in the urine.
 Cyanide
- 
 
Treatment:
Amylnitrite
Sodium nitrite
Sodium thiosulfate (IV)
 Carbon Monoxide poisoning

 This is non-irritating, tasteless, colorless, odorless

gas produced by incomplete combustion of any
carbon containing material.
 Smoke inhalation in fires, automobile exhaust fumes,
faulty or poorly ventilated charcoal, kerosene or gas
stoves, cigarette smoke and methylene chloride-
sources of exposure
 Carbon Monoxide

Mechanism of toxicity
Toxicity is a consequence of cellular hypoxia due to
decreased oxygen transport.

a. CO binds to Hgb with an affinity 25x of oxygen

producing carboxyhemoglobin saturation

b. Binds to other heme containing proteins such as

myoglobin and cytochrome A3.
 Toxic Dose

The permissible exposure limit to CO is 35 ppm as

an 8 hour time weighted average.

The level immediately dangerous to life or health is

1500 ppm.

Several minutes of exposure to 1000 ppm may result

in 50% saturation of carboxy Hgb and fatal
poisoning.
Carbon monoxide
-carbon
monoxide
intoxication
produces tissue
hypoxia as a
result of
decreased oxygen
transport
 
 Clinical Presentation

Patients with coronary heart disease manifest with

angina or more severely myocardial infarction.

Survivors of serious poisoning develop neurologic

sequelae which include parkinsonism and penalty and
memory disorder.
Symptoms:
Dyspnea, headache, visual disturbances,
tachycardia, syncope, tachypnea, coma, convulsion
-check blood carboxyhemoglobin level
 Diagnosis

Diagnosis is difficult.

There is no pathognomic symptom except for cherry

red color of face and bright red color of venous
blood.
 Laboratory Diagnosis

Uses CO-oximeter as a definitive diagnostic tool.

It measures the concentration of blood
carboxyhemoglobin.
 Treatment

100% oxygen and additional supportive treatment

Half-life of carboxyhgb without treatment is 3-4
hours depending on the patient’s ventilation.
Administration of 100% oxygen by face mask
shortens the half-life to 90 mins.
Arsenic
-ant poison,
rodenticide, herbicide,
weed killer,
insecticide, paint,
wood preservative,
ceramics, metal
alloys, livestock
feeds, tanning
agents, medicines
-can cross placenta
 
Arsenic 
Major toxicological
forms of arsenic:
Inorganic arsenicals:
-sodium arsenate
-lead or copper
arsenite
Organic arsenicals
-carbarsore
-tryparsamide
-arsine gas
 
 Arsine gas
-most dangerous form of arsenic
-irreversibly attach to sulfhydryl groups of
hemoglobin,
causing intravascular hemolysis,
hemoglobinemia, acute renal failure, direct
nephrotoxicity
 
Arsine gas
Symptoms:
Burning and dryness of mouth and throat,
difficulty in swallowing,
vomiting,
watery and bloody diarrhea containing shreds
of intestinal lining on mucus,
garlic breath,
metallic taste in patients mouth


Toxic effects:
Cyanosis,
hypotension,
tachycardia,
ventricular arrhythmias,
neuropathy,
hematemesis,
acute renal failure, cardiac damage,
anemia, hemolysis,
pulmonary edema
Diagnosis 
-analysis of hairs, nails, using emission
spectroscopy is important for diagnosis of
chronic arsenic poisoning
 
Treatment:
Gastric lavage, emesis, dimercaprol, British
anti-lewisite (BAL) combines with arsenic
through its sulfhydryl groups to produce water-
soluble complexes
-2,3-dithioerythriol
-hemodialysis
 ARSENIC

This is widely used in insecticides, rodenticides and

weed killers, paint. Wood preservatives, ceramics
and livestock feed.
Faster absorption in the GIT and lungs
24 hrs post ingestion, arsenic is distributed in all
body tissue and major route of excretion is kidney
Can cross the placenta and thus produce teratogenic
effects on fetus
 Toxic manifestation

Acute exposure- occurs after acute ingestion within 1

hour and reflects multi-organ involvemnet
a) Burning or dryness of mouth or throat
b) Difficulty in swallowing
c) Vomiting
d) Watery or bloody diarrhea containing sheds of
intestinal lining or mucus
e) Garlic odor of breath
f) Metallic taste in patient’s mouth
 Toxic manifestation

Multi organ involvement may show

a) Cyanosis
b) Hypotension
c) Tachycardia
d) Ventricular arrhythmia
e) Delirium
f) Coma
g) Neuropathy
 Diagnosis

Specific level >50 mg/L in 24 hr urine specimen is

abnormal
Analysis of urine, hair and nails using emission
spectroscopy(IES) is important for diagnosis of
chronic arsenic poisoning
 Treatment

1. Removal of residual arsenic by gastric lavage or

emesis
2. Dimercaprol or BAL ( british antilewisite) which
combines with arsenic through its sulfhydyl groups
3. Oral chelation therapy with penicillamine
 Environmental Carcinogen

1. Nitrites- used as preservatives in red meat causing

colon cancer.
2. Benzpyrenes- aromatic compound produced in
cigarettes & also in the exhaust of engines,
3. Aflatoxins- produced by fungus Aspergillus
causing hepatic carcinoma
4. Benzene and ionizing radiation- causes acute
leukemias
5. Vinyl chloride and thorotrast- used as dyes
and causes angiosarcoma
 BASIC TECHNIQUES FOR DETECTING DRUGS
IN SERUM AND URINE
 
2 TYPES:
1. Immunochemical methods
2. Chromatographic methods
 IMMUNOCHEMICAL METHODS
-homogenous immunoassay (performed in a single-step)
e.g., only one antibody is used
-rapid and stat analysis of blood and urine

1. EMIT (Enzyme Mediated Immunologic Technique)

-uses a drug-enzyme complex (marker) w/c is covalently linked to each other
-concentration of drug in sample is directly proportional to the enzymatic activity

2. FPIA (Fluorescent Polarization Immunoassay)

-sensitive and specific method (nanomolar range)
-uses a drug probe complex
-polarization is inversely proportional to concentration of dr
-Abbot laboratories (Chicago, Il) TDX, AXSYM analyzers
-Rosche Diagnostic Laboratories (Nutley, NJ) COBAS, INT
 CHROMATOGRAPHIC TECHNIQUES
 
Mainly for qualitative detection
TLC – Thin Layer Chromatography
HPLC – High Performance Liquid Chromatography
GC-MC – Gas Chromatography-Mass Spectroscopy (GOLD
STANDARD; volatile drugs and poisons)

Others:
CE – Capillary Electrophoresis
LC-MS – Liquid Chromatography-Mass Spectroscopy
 
1. TLC – Thin Layer Chromatography
-Polar solid stationary phase (usually hydrated silicate
-Non-polar mobile phase (10% methanol in
chloroform)
 
Principle:
-For a given solvent system, the ratio of the distance
transversed by the compound to the distance
transversed by the solvent front is a constant for the
compound and can be used to identify the compound i
the mixture, this ratio is called rf
 
1. TLC – Thin Layer Chromatography
- 
Applications:
-testing for drugs of abuse
-Toxi-Lab (Irvine, CA)
 
-Best specimen is urine
(because large quantities can be collected
noninvasively)
-identification by color change mechanism
(fluorescence)
 
1. TLC – Thin Layer Chromatography
-Steps:
-collection of samples
-concentration
-extraction (acidic separation from basic)
almost all drugs of abuse are basic drugs, al
of which are amine derivatives
-important acid drugs comprise almost
exclusively the barbiturates
 2. HPLC – High Performance Liquid
Chromatography
-quantitative detection (allows sharper separation)
-mainly utilized for quantitation of the tricyclic
antidepressants and their metabolites
-most commolnly prescribed drugs and are also
used in excess as drugs of abuse in suicide
attempts.
 
Stationary phase:
-Polar (silicic acid)
-non-polar (C-18 columns)
 3. GC-MC – Gas Chromatography-Mass Spectroscopy
-great sensitivity and reliability
 
Others:
LC-MC
-used for nonvolatile compounds
-confirmation for drugs of abuse, poisoning
detection in acute or chronic intoxication,
therapeutic drug identification and quantitation
-pharmacokinetic and drug metabolism studies.
THE DRUGS OF ABUSE
 SCREENING FOR DRUGS OF ABUSE
 
2 levels:
1. Emergency room testing
-rapid, stat screening methods
EMIT/FPIA/TLC
-sample: urine
 
2. Employment/Forensic testing
-GS-MC/HPLC
 
Note: Strictly by law, any confirmatory method
is valid, provided it is a completely different
method from the primary one.
 DRUGS
OF
ABUSE
OPIATES BARBITURATES; DOPAMINERGIC
-morphine sedatives-hypnotics PATHWAY
-naloxone (Narcan) STIMULANTS
-codeine -cocaine
-methadone -barbituric acid -benzoylecgonine
-heroine -phenobarbital (long-acting) -amphetamines
-propoxyphene (Darvon) -amobarbital (intermediate-acting) amphetamine
-pentobarbital (short-acting) methampethamine
HALLUCINOGENS -thiopental (ultra-short-acting) methylphenidate (Ritalin
-phencyclidine TRANQUILIZERS for hyperactive children)
-methaqualone -diazepam (Valium)  
-lysergic acid -oxazepam
diethylene (LSD)
-tetrahydrocannabinol
COCAINE
-cocoa plant derivative (food additive)
-beginning of the 20th century, used in
Coca-Cola
-derivative of the alkaloid ecgonine
(methyl ester of benzoylecgonine)
COCAINE
Fatal aspects:
-direct drug toxicity
-crime related to illicit acquisition

Administration:
-nasal (inhalation,snorting)
 
half-life:
1-2 hours (2 days in body)
 
Applications:
-local anesthesia (nasopharyngeal surgery)
-induction of euphoric state (‘HIGH’)
-induction of hallucinatory states
Effects:
can also promote violent behavior
many of the results of which is attributed
to its dopaminergic effects
-increase Ca ion (intracellular)
-increase dopamine
-neurotoxic
 Effects:
--general cytotoxic effects from formation
of an N-oxide free radical produced in the
metabolism of this compound in the liver.
-cardiotoxicity (progressive atherosclerosis)
-can pass in placenta and lactating
mammary glands (babies: mental retardation,
delayed development and strong drug
dependence and malformations in-utero)
 
Mechanism:
-induce release of beta-endorphins that bind to
mu-receptors in the limbic system giving a
pleasant and positive feeling of reinforcement.
 
OPIATES (morphine, codeine, heroine)
MORPHINE
-powerful analgesic
-treating acute congestive
heart failure by lowering
venous return to the heart

CODEINE
-mild analgesic and as an
antitussive
 CODEINE
-mild analgesic and as an antitussive

Half-life:
Intravenous – 3 minutes
Effects – 3 hours
 
Fatalities:
-coma
-respiratory arrest
 
Treatment;
-intravenous
naloxone
(Narcan)
-as a chronic
problem, is treated
pharmacologically
with a partial
agonist of heroine,
methadone
METHADONE
-nonbicyclic drug that binds
competitively with morphine to
mu-receptors in the brain
-less addictive than heroine
(binding affinity is lower)
AMPHETAMINES
bears close
-

resemblance to the
adrenergic amines such
as epinephrine and
norepinephrine and
may be expected to
exert sympathomimetic
effects.
AMPHETAMINES
-also resemble
dopamine and may also
be expected to have
effects on
dopaminergic
pathways.
 
AMPHETAMINES
Effects:
-cause euphoria
-increased mental awareness
-pronounced adrenergic effects
(delirium, confusion, delusion,
disorientation, hallucinations,
restlessness, homicidal and
suicidal tendencies, panic states,
paranoia)
 BENZODIAZEPINES
-Valium is most prominent in use
(minor tranquilizers)
 
Effects:
-calming (2.5-10 mg)
-muscle relaxing (higher doses)
-used by drug addicts to counter
the excitatory effects of other
drugs of abuse or as a means of
inducing tranquil states
-physical and psychological
dependence occur in chronic users
 
BENZODIAZEPINES

 
Half-life:
20-70 hours to 50-100 hours
 PHENCYCLIDINE Effects:
(PCP) -analgesic and
-used almost anesthetic and
exclusively as a drug stimulatory
of abuse -a wide variety of
-‘angel dust’/’angel bizaare and apparently
hair’ paradoxical symptoms
  can be seen in the
same patient.
 BARBITURATES: sedative-
BARBITURATES: hypnotics
sedative-hypnotics  
  Effects:
-sedation
Barbituric acid -drowziness
-condensation product -sleep
of urea and malonic acid -impairment of judgement
-anesthetic (high-does)
-anticonvulsants -stupor, coma, death (lethally
-fat soluble and high-dose)
therefore pass easily
across the blood-brain
barrier
 PROPOXYPHENE PROPOXYPHENE
(DARVON) (DARVON)
-analgesic (similar
pharmacologically to Effects:
opiates and -same as opiates
morphine) -nephrogenic diabetes
insipidus
 
 
Treatment:
Naloxone (Narcan)
METHAQUALO METHAQUALO
NE NE (QUAALUDE)
(QUAALUDE) -anticonvulsant
-Half-life: -antispasmodic
Serum 20-60 -local anesthetic
-antitussive
hours
 
 
Effects:
Hypnotic and
sedative
(150-300 mg/day)
 MARIJUANA (CANNABIS)
-one of the oldest and most widely used of the
mind altering drugs
-a mixture of cut, dried, and ground portions
of the hemp plant Cannabis sativa
Hashish refers to a more potent product
produced by extraction of the resin from the plant
 
Delta-9-tetrahydro cannabinol (THC)
-principal psychoactive agent in marijuana
-lipid-soluble; readily enters the
brain and may act by producing cell membrane changes
 
 MARIJUANA (CANNABIS)
-Administration
-oral
-smoking
 
Half-life:
-1 week
-1-4 weeks (detection in urine)
 
Effects:
-reddening of conjunctiva
-increased pulse rate
-muscle weakness
-deterioration in motor coordination
LYSERGIC ACID DIETHYLAMIDE
(LSD, LYSEGIDE)
-semisynthetic indolalkylamine and
hallucinogen
-one of the most potent pharmacological
materials known, producing effects at doses
as low as 20 ug
 
Administration:
-injection
-oral
 
LYSERGIC ACID DIETHYLAMIDE (LSD, LYSEGIDE)
-Effects;
-CNS hyperarousal
-hypertension
-panic reactions
-‘BAD TRIP’
-mydriasis
-piloerection
-tachycardia
 
Treatment:
-diazepam
METHODS FOR IDENTIFYING AND
MEASURING ABUSED DRUGS
 METHODS FOR IDENTIFYING AND MEASURING ABUSED DRUGS

Sample Requirement : Urine, Serum, Hair, Nails, Whole Blood or

Plasma (Alcohol), Sweat, Saliva, and Exhaled Breath (Alcohol
Intoxication)

1. Enzymatic Test
 Alcohol is measured from blood using alcohol dehydrogenase
as reagent.
 It quantitates the sum of all alcohols present in a sample.
 It does not distinguish alcohols from its metabolites during
quantitation.
METHODS FOR IDENTIFYING AND MEASURING
ABUSED DRUGS
2. Capillary Electrophoresis
 Different analyte selectively is based on different physiochemical principles
of separation without changes in istrumental hardware, a distinct advantage
of this technique.
 Recent variant of TLC that includes the advantages of HPI.C

3. Homogenous Immunoassay
 This assay is done in one solution without separation.
 Enzyme Mediated Immonologic Technique (EMIT)
- This method uses enzyme-labeled drug that competes with the drug in the
sample.
METHODS FOR IDENTIFYING
- In this reaction, AND
the active site of MEASURING
the enzyme ABUSED
is blocked DRUGS
with the
antidrug antibody, resulting to decreased enzymatic activity.
- The free drug (analyte in the serum or urine) competes with the
antibody-drug-enzyme complex.

4. Chromatographic Methods
a. Thin Layer Chromatography (TLC)
 This method uses serum, urine or gastric fluid for analysis.
 Extraction of drugs is pH dependent - acidic drugs at pH 4.5
(barbiturates) and alkaline drugs (opiates, amphetamines) at pH 9.0
METHODS FOR IDENTIFYING AND MEASURING ABUSED DRUGS

b. Liquid Chromatography-Mass Spectrospcopy (LC-MS)

 It can be used to confirm positive test results from a screening assay
(nonvollatile compounds)
 It can also be used for detection of poisons in acute or chronic intoxication,
therapeutic drug identification and quantitation, pharmakinetics and drug
metabolism studies.

c. High Performance Liquid Chromatography (HPLC)

 It allows quantitative measurement of drugs as well as separation of these
same drugs, especially tricyclic antidepressants including its active and
inactive metabolites.
METHODS FOR IDENTIFYING AND MEASURING
ABUSED
 It may be used as DRUGS
an alternative to GC-MS in definitive
identification of drugs.

d. Gas Chromatography
 GLC - It is Legally accepted method for ethanol testing
 GC with Infrared Spectroscopy - For detection of
amphetamines
 GC-MS - Gold standard for confirmation of screening
methods such as TLC and EMIT. Allows for detection of
low levels of drugs like coccaine and drug metabolites.
METHODS FOR IDENTIFYING AND MEASURING ABUSED
Notes to remember : DRUGS

 Urine sample for Toxicology assay has the advantage of

knowing the complete composite of drugs that have been
ingested over a longer period than Blood Samples.
 Once a urine specimen is collected, it is subjected to
concentration and extraction procedures. In extraction
procedures, acidic drugs are separated from basic ones.
 Examination of blood has the advantage of identifying
currently circulationg drugs and to design treatment
plan and monitoring the succes of treatment.
 Drugs when deposited in hair, are generally present in
relatively low levels.
 For sweat testing, parent drug is increased than
metabolites.
 For saliva testing, drug concentration in it reflects the
free or active fraction.
 2 basic techniques for identification of drugs :
immunochemical and chronmatography
Urine is the Preferred sample especially in
drug testing because :

1. Drugs and their metabolites are present in higher

concentrations in urine than in blood.
2. Larger sample volumes are easily collected
3. There is no pain or discomfort when collecting the
sample
4. The process of obtaining the sample is
noninvasive.
Factors Resulting to Incorrect drug testing result :

1. Pressence of detergents will result to alkaline pH

2. Use of sodium chloride
3. Low specific gravity (diluted urine)
4. high pH (alkaline urine)
5. Blood in urine (Hematuria)