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PubMed2005

Determination of dextromethorphan and its metabolite dextrorphan in human urine using high performance liquid chromatography with atmospheric pressure chemical ionization tandem mass spectrometry: a study of selectivity of a tandem mass spectrometric assay.

Analytical method for the simultaneous determination of dextromethorphan (1) and dextrorphan (2) in urine, based on solid-phase extraction of drug from acidified hydrolyzed biological matrix, were developed. The analytes (1 and 2) and the internal standard (levallorphan, 3, IS) were detected by high-performance liquid chromatography-mass spectrometry (HPLC-MS/MS) in positive ionization mode using a heated nebulizer (HN) probe and monitoring their precursor-->product ion combinations of m/z 272-->215, 258-->201, and 284-->201 for 1, 2, and 3, respectively, in multiple reaction monitoring mode. The analytes and IS were chromatographed on a Keystone Prism reverse phase (50 mm x 2.0 mm) 5 microm column using a mobile phases consisting of a 35/65 or 27/73 mixtures of methanol/water containing 0.1% TFA adjusted to pH 3 with ammonium hydroxide pumped at 0.4 ml/min for 1 and 2, respectively. The limits of reliable quantification of 1 and 2 were 2 and 250 ng/ml, respectively, when 1 ml of urine was processed. The absence of matrix effect was demonstrated by analysis of neat standards and standards spiked into urine extracts originating from five different sources. The linear ranges of the assay were 2-200 and 250-20,000 ng/ml for 1 and 2, respectively. Assay selectivity was evaluated by monitoring the "cross-talk" effects from other metabolites into the MS/MS channels used for monitoring 1, 2, and 3. In addition, an interfering peak originating from an unknown metabolite of 1 into the quantification of dextromethorphan was detected, requiring an effective chromatographic separation of analytes from other metabolites of 1. The need for careful assessment of selectivity of the HPLC-MS/MS assay in the presence of metabolites, and the assessment of matrix effect, are emphasized.

Antitussive Agents↗
PubMed2006

The intravenous ketamine test predicts subsequent response to an oral dextromethorphan treatment regimen in fibromyalgia patients.

UNLABELLED: Fibromyalgia (FM) is a challenging pain syndrome for which no reliable pharmacologic treatment exists. Recent clinical studies suggest that N-methyl-D-aspartate receptors might play a role in the pathogenesis of this disorder. To determine whether an intravenous (IV) ketamine test predicts the response to a therapeutic trial with an oral N-methyl-D-aspartate receptor antagonist, we performed a low-dose (0.1 mg/kg) IV ketamine infusion on 34 consecutive patients with FM, which was subsequently followed by an oral dextromethorphan (DX) treatment regimen. As per previous guidelines, the cutoff value for a positive response to the IV ketamine test was designated to be 67% pain relief, and a positive response to DX treatment was 50% pain reduction at 4- to 6-week follow-up visits. The degree of correlation between pain relief with ketamine and DX was highly significant (Pearson correlation coefficient, 0.66; P < .001). Ten patients responded positively to both ketamine and DX, 19 responded to neither drug, 3 had a positive response to ketamine but not DX, and 2 obtained good pain relief with DX but not ketamine. The sensitivity of the IV ketamine test was 83%, the specificity was 86%, the positive predictive value was 77%, and the negative predictive value was 91%. An association was also found between the development of side effects to the two treatments. PERSPECTIVE: The response to an IV ketamine infusion was found to predict the subsequent response to an oral dextromethorphan treatment regimen in fibromyalgia patients, with an observed agreement of 83%. Considering the refractory nature of fibromyalgia to conventional pain treatments, the IV ketamine test might enhance patient care by saving time and reducing unnecessary treatment trials.

Administration, Oral↗
PubMed2004

Development of a chromatographic bioreactor based on immobilized beta-glucuronidase on monolithic support for the determination of dextromethorphan and dextrorphan in human urine.

We here reported the development and application of an immobilized enzyme reactor (IMER) based on beta-glucuronidase to the on-line determination of urinary molar ratios of dextromethorphan (DOMe)/dextrorphan (DOH) for the assessment of the metabolic activity of CYP2D6, a genetically variable isoform of cytochrome P-450 (CYP). beta-Glucuronidase was immobilized on an HPLC monolithic aminopropyl silica support. Catalytic activity and stability of the chromatographic reactor were evaluated using 8-hydroxyquinoline glucuronide (8-HQG) as substrate. The IMER was coupled through a switching valve to a reversed-phase column (C8) for the simultaneous determination of dextromethorphan and its main metabolite dextrorphan. On purpose a selective reversed-phase ion pair HPLC method coupled with fluorescence detection was developed. Urine samples were first centrifuged to remove insoluble materials and then aliquots of the supernatants were injected into the coupled-column analyser. Linearity, precision and accuracy of the method were established. The method reliability was verified by comparing our data with previous data of a phenotyping study carried out by the Poison Control Centre of Pavia-Clinical Toxicology Division.

Chromatography, High Pressure Liquid↗
PubMed2004

Oral dextromethorphan reduces perioperative analgesic administration in children undergoing tympanomastoid surgery.

OBJECTIVE: To determine whether oral dextromethorphan (1 mg/kg) given one hour prior to surgery decreases opioid administration in the perioperative period in children undergoing tympanomastoid surgery. METHODS: This was a prospective randomized double-blinded and placebo-controlled study in which 20 male and 18 female children (age 11.5 +/- 3.5 years) were enrolled. Nineteen children received dextromethorphan (DM), while the other 19 received placebos. Postoperative pain was assessed using a visual analogue scale and a pain score of > or =5 was treated with intravenous morphine sulfate. Patients were discharged home on oral oxycodone. RESULTS: The total doses of fentanyl administered during surgery were higher in the placebo group compared to the DM group (4.1 +/- 2 vs 2.6 +/- 1.4 microg/kg, P = 0.02) and the total doses of intravenous morphine administered in the postoperative period were also higher in the placebo group compared to the DM group (150 +/- 80 vs 73 +/- 56 microg/kg, P = 0.004). The placebo group had a higher pain score at the time of admission to the Day Surgery Unit (DSU) and a higher maximum pain score, compared to the DM group, during their combined stay in the Post-Anesthesia Care Unit and DSU (7.3 +/- 1.5 vs 3.1 +/- 2.6, P = 0.001). CONCLUSIONS: Premedication with DM reduces the need for opioid administration in the perioperative period in children undergoing tympanomastoid surgery. EBM RATING: A.

Administration, Oral↗
PubMed2006

Effects of dextromethorphan on rats' acquisition of responding with delayed reinforcement.

Separate groups of 16 rats received 0, 40, 60, or 80 mg/kg dextromethorphan prior to a 2-h response-acquisition session during which responses on one lever produced food (reinforcement lever, RL, responses) after a 15-s resetting delay and responses on the other lever cancelled food deliveries earned by RL responses, but otherwise had no programmed consequences. When compared to the 0 mg/kg dose, the 40, 60, and 80 mg/kg doses significantly decreased the latency to the tenth RL response, which has been used previously as an index of response acquisition [Pallares, MA, Nadal, RA, Silvestro, JS, Ferre, NS. Effects of ketamine, a noncompetitive NMDA antagonist, on the acquisition of the lever-press response in rats. Physio Behav 1995; 57:389-392.]. Only the 80 mg/kg dose, however, significantly reduced the total number of food pellets earned, the total number of RL responses, or the total number of rats that met the criterion for response acquisition. The present results indicate that dextromethorphan can disrupt initial response acquisition (i.e., learning) with positive reinforcement, although the dose that did so depended on the measure used to index performance. Moreover, the effects of the drug did not appear to reflect specific learning impairment, but rather more general disruption of behavior.

Analgesics, Opioid↗
PubMed2006

Dextromethorphan premedication reduced postoperative analgesic consumption in patients after oral surgery.

OBJECTIVE: N-methyl-D-aspartate (NMDA) receptor antagonist premedication reduces postoperative pain. In this study, we examined if NMDA antagonist premedication might reduce postoperative pain after oral surgery, testing dextromethorphen. STUDY DESIGN: One hundred eleven patients undergoing mandibular third molar extraction under local anesthesia were included. Patients were randomly allocated into 3 groups. Group A (n = 37), B (n = 38), and C (n = 36) patients were emphasis-placed on dextromethorphan 30 mg, diclofenac 25 mg, or placebo orally before surgery, respectively. Postoperatively, patients were allowed to use oral diclofenac, 25 mg, for postoperative pain relief. Postoperative pain was evaluated the 1st, 7th, and 14th day after surgery, respectively, by using a visual analog scale (VAS) and the number of diclofenac consumed. VAS score and the number of diclofenac consumption were compared among the groups. RESULTS: VAS score was similar among the 3 groups during the study period. Total postoperative diclofenac consumption was significantly less in group A than in group C (P < 0.05). CONCLUSION: Dextromethorphan premedication reduced postoperative analgesic consumption after oral surgery.

Administration, Oral↗
PubMed2002

Differential antinociception by morphine and methadone in two sub-strains of Sprague-Dawley rats and its potentiation by dextromethorphan.

The antinociceptive effect of morphine and methadone was tested in two substrains of Sprague-Dawley (SD) rats, from B&K Universal, Sweden (BK) and Mollegård, Denmark (DK). In both sub-strains of SD rats subcutaneous morphine or methadone produced dose-dependent antinociception on the hot plate test. However, the effect of the opioids was less in DK-SD than BK-SD rats, particularly for morphine as it failed to produce maximal antinociception even at high doses. Dextromethorphan, a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist, potentiated the antinociceptive effect of morphine and methadone in the DK-SD rats. The potentiation of morphine by dextromethorphan was significantly greater than its effect on methadone at equipotent doses. The results showed that there is a sub-strain difference for SD rats in the response to the antinociceptive effect of opioids, which may be due to greater NMDA receptor activity in DK-SD than in BK-SD rats. The higher efficacy of methadone may be derived from its proposed NMDA receptor blocking property and/or high intrinsic activity.

Analgesics, Opioid↗
PubMed1992

Dextromethorphan and high-dose benzoate therapy for nonketotic hyperglycinemia in an infant.

To test the hypothesis that nonketotic hyperglycinemia causes overstimulation of the excitatory N-methyl-D-aspartate receptor by allosteric glycine activation, and that reduction of glycine and blocking of the cation channel coupled to the receptor would be beneficial, we administered benzoate and dextromethorphan, a blocker of the N-methyl-D-aspartate channel to an infant with nonketotic hyperglycinemia. Therapy with benzoate, 500 mg/kg per day, was started on day 5, and the dosage was increased to 750 mg/kg per day on day 8, with prompt normalization of the neurologic and electroencephalographic findings. The glycine concentrations in both plasma and cerebrospinal fluid were substantially reduced. Dextromethorphan was added to the regimen on day 12. The electroencephalogram remained normal until the infant was 8 months of age, when diffuse slowing became apparent. Serial brain magnetic resonance imaging showed delayed myelination. At 12 months of age, physical examination findings and growth were normal except for hypotonia. The developmental quotient was approximately 60, and the child was free of seizures. This outcome, although not ideal, is better than that typical for nonketotic hyperglycinemia. Our results suggest that trials with additional patients and other N-methyl-D-aspartate cation channel blockers are warranted.

Benzoates↗
PubMed2001

High-performance liquid chromatography assay for simultaneous determination of dextromethorphan and its main metabolites in urine and in microsomal preparations.

An HPLC method has been developed and validated for the determination of dextromethorphan, dextrorphan, 3-methoxymorphinan and 3-hydroxymorphinan in urine samples. Deconjugated compounds were extracted on silica cartridges using dichloromethane/hexane (95:05, v/v) as an eluent. Chromatographic separation was accomplished on a Phenyl analytical column serially connected with a Nitrile analytical column. The mobile phase consisted of a mixture of an aqueous solution, containing 1.5% acetic acid and 0.1% triethylamine, and acetonitrile (75:25, v/v). Compounds were monitored using a fluorescence detector. Calibration curves were linear over the range investigated (0.2-8.0 microM) with correlation coefficients >0.999. The method was reproducible and precise. Coefficients of variation and deviations from nominal values were both below 10%. For all the analytes, recoveries exceeded 77% and the limits of detection were 0.01 microM. The validated assay proved to be suitable for the determination of DEM metabolic indexes reported to reflect the enzymatic activity of the cytochrome P450s, CYP2D6 and CYP3A, both in vivo, when applied to urine samples from patients, and in vitro, when applied to samples from the incubation of liver microsomes with dextromethorphan.

Aryl Hydrocarbon Hydroxylases↗
PubMed1996

High performance liquid chromatography determination of dextromethorphan and its metabolites in urine using solid-phase extraction.

A high performance liquid chromatography assay coupled with fluorescence detection was developed for the determination of dextromethorphan and its metabolites in urine. The products and the internal standard, pholcodine, were separated on an Alltima C18, 5 microns column (250 x 4.6 mm), using a mobile phase containing sodium dodecyl sulphate (1 mM) in a mixture of acetonitrile-sodium dihydrogen phosphate (0.01 M) 40.5:59.5, v/v) (pH* = 2.5). A novel solid-phase extraction procedure with strong cation exchange, non end-capped, Isolute SCX cartridges allows good recovery of the products (mean 85% or more). For all analytes, the assay is sensitive (LOQ 25 ng ml-1, using 200 microliters urine), reproducible (RSD < 15%) and accurate (< 15% deviation of the nominal value) over the range evaluated. This method can be used to measure dextromethorphan and its metabolites to phenotype individuals as poor or extensive metabolizers of drugs metabolized by CYP2D6.

Acetonitriles↗
PubMed1998

Simultaneous determination of dextromethorphan HBr and bromhexine HCl in tablets by first-derivative spectrophotometry.

A rapid, simple and direct assay procedure based on first-derivative spectrophotometry, using a zero-crossing and peak-to-base measurement at 234 and 324 nm, respectively, has been developed for the specific determination of dextromethorphan HBr and bromhexine HCl in tablets. Calibration graphs were linear with the correlation coefficients of 0.9999 for both analytes. The limit of detections were 0.033 and 0.103 microgram ml-1 for dextromethorphan HBr and bromhexine HCl, respectively. A HPLC method has been developed as the reference method. The results obtained by the first-derivative spectrophotometry were in good agreement with those found by the HPLC method.

Antitussive Agents↗
PubMed2000

Evidence for the catalysis of dextromethorphan O-demethylation by a CYP2D6-like enzyme in pig liver.

The pig is increasingly being used in pharmacological and toxicological studies, and is the species of choice for future research into xenotransplantation, extracorporeal liver support and hepatocyte-based bioartificial liver. However, relatively little is known about xenobiotic-metabolizing enzymes in this species. In the present study, immunoblotting with polyclonal anti-rat and anti-human cytochrome P450 (CYP) antibodies revealed the presence of proteins in pig liver which cross-reacted with anti-human CYP1A2, CYP2D6 and CYP3A4, and with anti-rat CYP2E1 antibodies. Northern blot analysis demonstrated the presence of mRNA which hybridized to cDNA probes for human CYP2D6, CYP2E1 and CYP3A4, and to an oligonucleotide probe for pig CYP3A29. As there is a lack of a good animal model for CYP2D6, the presence of a CYP2D6-related protein in pig liver was of particular interest. Pig hepatocytes also demonstrated CYP2D6 immunoreactive protein, and mRNA hybridizable to a CYP2D6 cDNA probe. We investigated the ability of pig liver microsomes to catalyse dextromethorphan O-demethylation, a widely-used marker enzyme activity for CYP2D6. This enzyme activity demonstrated biphasic kinetics, with a high affinity apparent K(m1)=6.9+/-3.6 microM and V(max1)=10.5+/-6.1nmol/min/nmol CYP. The reaction was sensitive to inhibition by the CYP2D6-selective inhibitors quinidine, quinine, lobeline and norfluoxetine, whereas chemical inhibitors selective for other CYP isoforms failed to affect the reaction. We conclude that dextromethorphan O-demethylation is catalysed by a CYP2D enzyme which is remarkably similar to human CYP2D6, suggesting potential value of the pig as a model for predicting human metabolism of xenobiotics which undergo CYP2D6-dependent biotransformation.

Animals↗
PubMed2003

Rates of metabolism of chlorzoxazone, dextromethorphan, 7-ethoxycoumarin, imipramine, quinidine, testosterone and verapamil by fresh and cryopreserved rat liver slices, and some comparisons with microsomes.

In the present study we have investigated the disappearance of chlorzoxazone, dextromethorphan, 7-ethoxycoumarin, imipramine, quinidine, testosterone and verapamil from the medium in which fresh and cryopreserved rat liver slices were incubated. These compounds are all substrates of major isoforms of cytochrome P450 expressed in the liver. The metabolism of five of these compounds in microsomes from rat liver was also examined. Determinations of the concentrations of the compounds were performed employing LC/MS. Intrinsic clearance values (CL(ints)) were calculated on the basis of the concentration-vs.-time curves. No significant differences in the CL(int) values obtained with fresh and cryopreserved rat liver slices were observed for any of the compounds. The highest CL(int) value estimated with liver slices was observed for testosterone and the lowest values were with chlorzoxazone and 7-ethoxycoumarin. The total CL(int) values for 7-ethoxycoumarin and imipramine, calculated using scaling factors, were similar for liver slices and microsomes. In the case of testosterone, this total CL(int) was approximately 3.7-fold lower, whereas for dextromethorphan and quinidine it was 2.5- and 8.5-fold higher, respectively, with liver slices than with microromes. In conclusion, the rate of metabolism of the seven compounds tested with rat liver slices was not affected by cryopreservation. This finding adds further support to the general conclusion that the major activities involved in drug metabolism are not affected by cryopreservation of rat liver slices.

Animals↗
PubMed1989

Assessment of the debrisoquin and dextromethorphan phenotyping tests by gaussian mixture distributions analysis.

From a sample of 149 unrelated Spaniards, individuals were phenotyped for their ability to hydroxylate debrisoquin and O-demethylate dextromethorphan. The distribution of urinary metabolic ratios for each test was analyzed by univariate gaussian mixture distributions analysis to determine the number of populations, the mean and standard deviation of the metabolic ratios for each population, and the proportion belonging to each population. For the 124 subjects phenotyped with both the debrisoquin and dextromethorphan tests a bivariate analysis was performed. The results demonstrate that both tests similarly separated this sample into two populations, with 10% belonging to poor metabolizer phenotypes. In addition, the correlation between the metabolic ratios from each test is significant, indicating that they are measuring the same biologic trait and the certainty of correctly identifying the debrisoquin oxidation phenotype of an individual is improved by using the results of both tests.

Debrisoquin↗
PubMed1989

Dextromethorphan O-demethylation in liver microsomes as a prototype reaction to monitor cytochrome P-450 db1 activity.

Liver dextromethorphan O-demethylation to dextrorphan is associated with the debrisoquin type of oxidation phenotype in humans. We studied dextromethorphan oxidation in vitro using human liver microsomes to investigate the kinetics of the polymorphic monooxygenase (cytochrome P-450 db1) and factors that may influence its activity. In microsomal preparations from six extensive metabolizers the reaction parameters were: Michaelis-Menten constant = 3.4 +/- SD 1.0 mumol/L and maximum rate of metabolism = 10.2 +/- 5.3 nmol x mg P-1 x hr-1, vs 48 mumol/L and 2.2 nmol x mg P-1 x hr-1, respectively in microsomes prepared from the liver of one poor metabolizer. The reaction was inhibited by nonspecific monooxygenase inhibitors such as SKF 525-A (Ki = 100 nmol/L) and cimetidine (Ki = 40 mumol/L), by known substrates of the polymorphic isozyme such as [+]-bufuralol (Ki = 7.5 mumol/L), debrisoquin (Ki = 25 mumol/L), and sparteine (Ki = 45 mumol/L), and by the selective cytochrome P-450 db1 inhibitor quinidine (Ki = 15 nmol/L). This assay permits in vitro screening for candidate substrates or inhibitors of the polymorphic isozyme.

Cytochrome P-450 CYP2D6↗
PubMed2000

Frequencies of CYP2D6 mutant alleles in a normal Japanese population and metabolic activity of dextromethorphan O-demethylation in different CYP2D6 genotypes.

AIMS: To determine the frequencies of 11 CYP2D6 mutant alleles (CYP2D6*2, *3, *4, *5, *8, *10, *11, *12, *14, *17 and *18), and their relation to the metabolic capacity of CYP2D6 in Japanese subjects. METHODS: One hundred and sixty-two unrelated healthy Japanese subjects were genotyped with the polymerase chain reaction amplification method and 35 subjects were phenotyped with dextromethorphan. RESULTS: The frequencies of CYP2D6*2,*5, *10 and *14 were 12.9, 6.2, 38.6 and 2.2% in our Japanese subjects, respectively. CYP2D6*3, *4, *8, *11, *12, *17 and *18 were not detected. The mean log metabolic ratio of dextromethorphan in subjects with genotypes predicting intermediate metabolizers was significantly greater than that of heterozygotes for functional and defective alleles. CONCLUSIONS: CYP2D6*5 and CYP2D6*14 are the major defective alleles found in Japanese subjects. In addition, CYP2D6*10 may play a more important role than previously thought for the treatment of Japanese patients with drugs metabolized by CYP2D6.

Adult↗
PubMed1998

Dextromethorphan and pain after total abdominal hysterectomy.

Dextromethorphan is an N-methyl-D-aspartate (NMDA) receptor antagonist which has been shown to inhibit the development of cutaneous secondary hyperalgesia after tissue trauma. We studied 60 ASA I-II patients undergoing total abdominal hysterectomy in a randomized, double-blind, placebo-controlled study. Patients received either dextromethorphan 27 mg capsules, two doses before operation and three doses in the first 24 h after operation, or placebo. Visual analogue pain scores (VAS) at 24 and 48 h were assessed at rest, on coughing and on sitting up, and were not significantly different between groups. Morphine consumption from a patient-controlled analgesia (PCA) device was also not significantly different between groups. Evidence of secondary hyperalgesia was assessed with von Frey hairs 10 cm above the Pfannenstiel incision. Both groups of patients exhibited evidence of secondary hyperalgesia after 24 and 48 h but there were no significant differences between groups. There was also no difference between groups in VAS scores at 1 month.

Adult↗
PubMed1999

Preoperative oral dextromethorphan does not reduce pain or analgesic consumption in children after adenotonsillectomy.

UNLABELLED: In this randomized, double-blinded, placebo-controlled, prospective study, we evaluated the analgesic efficacy of dextromethorphan 0.5 mg/kg or 1.0 mg/kg p.o. 1 h before adenotonsillectomy in 57 children 6-12 yr of age. Anesthetic management was standardized. Morphine 0.075 mg/kg i.v. and acetaminophen 25-35 mg/kg p.r. were administered after anesthetic induction but before the start of surgery. A 4-point behavioral score (1 = asleep, 2 = awake and calm, 3 = awake and crying, 4 = thrashing) was recorded on admission to and discharge from the postanesthesia care unit (PACU). In the PACU, pain was assessed with Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and recorded every 15 min until the patient was transferred to the day surgery unit (DSU). In the DSU, patients rated their pain using a 10-cm baseline 0-10 visual analog pain scale (VAS) every 30 min until they were discharged home. A 24-h VAS was obtained by phone interview, and parental satisfaction was scored (yes/no) regarding their child's postoperative analgesia. Morphine 0.025 mg/kg i.v. was administered to children with CHEOPS score >6, who verbalized pain, or who were crying in any consecutive 5-min observation periods in the PACU. Total morphine consumption was recorded. The study groups were comparable with respect to demographic variables. We were unable to detect any differences between study groups with respect to postoperative morphine consumption, CHEOPS, behavior scores, VAS, or parental satisfaction. IMPLICATIONS: Premedication with dextromethorphan 0.5 or 1.0 mg/kg p.o. does not improve postoperative analgesia in school-aged children who receive preemptive morphine 0.075 mg/kg i.v. and acetaminophen 25-35 mg/kg p.r. during nitrous oxide and desflurane anesthesia for adenotonsillectomy.

Acetaminophen↗