Journal of Analyt ical Toxicology, Vol. 31, September 2007

Case Report ]

Domestic Abuse of the European Rave Drug Prolintane

Patrick B. Kyle* and Wil l iam P. Daley Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi 39216

Abstract

prolintane is a sympathomimetic amine with pharmacologic properties similar to d-amphetamine. Side effects include insomnia, nervousness, and irritability. Overdoses of prolintane may cause hallucinations, psychosis, and death. The drug is commonly prescribed in Africa, Australia, and Europe but is not available in the United States. This manuscript reports the first medically documented cases of prolintane abuse in the United States. In the first, a 34-year-old male presented to the emergency department confused, agitated, and unable to follow commands. Initial drug and alcohol screens were negative, but analysis by gas chromatography--mass spectrometry (GC-MS) indicated the presence of amitriptyline, nortriptyline, nicotine, and prolintane. The second patient, a healthy 26-year-old female, presented to the emergency department after intrauterine fetal death and spontaneous delivery. GC-MS revealed the presence of multiple drugs, including cannabinoids, cocaine, nicotine, hydrocodone, and prolintane. The medical and scientific communities should be aware of the potential for prolintane abuse because it may cause symptoms similar to those of the amphetamines but is not likely to be detected by a routine urine drug screen.

Introduction

Rave drugs (a.k.a. Club Drugs) are a wide variety of drugs used by young adults at rave parties, clubs, and bars for their psychotropic effects. The drugs most commonly abused in- clude marijuana, cocaine, gamma-hydroxybutryrate (GHB), methamphetamine, methylenedioxymethamphetamine (MDMA, ecstasy), lysergic acid diethylamide (LSD), and ke- tamine (1,2). Prolintane (Catovit, Promotil, Villescon) has been popular at rave parties in Europe (3) but has not been reported in the United States until now.

Prolintane is a CNS stimulant with structural and pharma- cologic properties similar to d-amphetamine (4) (Figure 1). Adverse effects of the drug include insomnia, nervousness, irritability, and dizziness (5). Prolintane, like many

* Author to whom correspondence should be addressed: Patrick B. Kyle, Ph.D., Department of Pathology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. E-mail: pkyte@pathology.umsmed.edu.

amphetamine derivatives, increases the concentration of dopamine in the synaptic cleft (6). Large amounts of prolintane may cause hallucinations and psychosis (6,7). Individuals who abuse prolintane risk becoming dependent as tolerance may develop.

Prolintane is commonly prescribed for the treatment of narcolepsy and attention deficit hyperactivity disorder in Africa, Australia, and Europe, where it has been compounded with multivitamins and made available in tonic or tablet form. The use of prolintane as a doping agent in athletics has been noted worldwide. Prolintane is prohibited from use by athletes in international and domestic competition by the World Anti-Doping Agency (8) and the National Colle- giate Athletic Association (NCAA). Prolintane is not legally available in the United States; it is neither listed by the U.S. Pharmacopoeia nor scheduled by the U.S. Drug Enforce- ment Association.

Two unrelated cases of prolintane abuse and overdose are presented in this report. These are the first medically docu- mented cases of prolintane abuse in the United States.

Case Histories

Case 1 A 34-year-old Caucasian male arrived at the emergency

department after being found lying on the floor. The patient presented with confusion, agitation, and unintelligible speech;

A B C

Figure I. Structures of amphetamine (A), methamphetamine (B), and pro- lintane (C).

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Journal of Analytical Toxicology, Vol. 31, September 2007

he was responsive to painful stimuli but unable to follow com- mands. His vital signs were temperature 37.8~ pulse rate 127 bpm, respiratory rate 18/min, and BP 141/101. The patient's skin was dry and warm. His pupils were 3--4 mm diameter and sluggish. He scored 10 (eyes 4, verbal 2, motor 4) out of 15 on the Glasgow Coma Scale. An electrocardiogram indicated sinus tachycardia. Naloxone was administered with no effect. The patient was also administered activated charcoal, sorbitol, cef- triaxone, lorazepam, and intravenous (I.V.) saline. He was re- strained after repeated attempts to remove his I.V. lines and to strike healthcare workers. An initial urine drug screen was negative. Analysis of the patient's urine by gas chromatog- raphy-mass spectrometry (GC-MS) revealed the presence of amitriptyline, nicotine, nortriptyline, and relatively high con- centrations of prolintane and metabolites (quantification not available). After regaining his faculties, the patient reported using drugs at his girlfriend's house the previous evening.

Case 2 A healthy 26-year-old African-American female presented to

the emergency department after intrauterine fetal death and spontaneous delivery. Initial physical exam showed an other- wise healthy patient with an intact placenta. Her blood pressure and heart rate were elevated (BP 172/106, HR 92 bpm), but other vital signs were unremarkable. The patient acknowl- edged recent use of tobacco, marijuana, and pain medication. Her initial urine drug screen was positive for cannabinoids, co- caine metabolites, and opiates. Subsequent analysis by GC-MS detected carboxytetrahydrocannabinol, cocaine, dihy- drocodeine, hydrocodone, methylecgonine, nicotine, 1.36 IJg/mL prolintane, and an estimated 17.9 Bg/mL of combined prolintane metabolites.

Materials and Methods

Reagents Type I water was acquired via a Millipore water filtration

system (Billerica, MA). All other solvents were purchased from Fisher Scientific (Fair Lawn, N J) and were of high-performance liquid chromatography (HPLC) grade or higher.

Sodium phosphate, proadifen hydrochloride (SKF-525A), and 2-amino-5-chlorobenzophenone were each 95% or higher purity as purchased from Sigma-Aldrich Corp. (St. Louis, MO). Prolintane (purity > 96% by HPLC) was received as a gift from Dr. Stefan Toennes (University of Frankfurt, Frankfurt, Ger- many).

Immunoassay screening The urine samples of both patients were screened for drugs

of abuse using Dade Behring Flex | reagents (Dade Behring, Deerfield, IL) on a Dade Behring Dimension | RxL. The cutoff limits for each assay were as follows: 500 ng/mL for am- phetamines, 200 ng/mL for barbiturates, 200 ng/mL for ben- zodiazepines, 150 ng/mL for benzoylecgonine, 50 ng/mL for cannabinoids, 300 ng/mL for opiates, and 25 ng/mL for phen- cyclidine.

Subsequent experimentation involved the addition of pro- lintane HCI to drug-free urine. Immunoassay screens were performed on known concentrations of prolintane in urine using the Dade Behring Flex amphetamine reagent (cutoff 500 ng/mL) and the Syva | EMIT ~ II Plus amphetamine reagent (cutoff 300 ng/mL) to determine the cross-reactivity of the reagents to the drug.

GC-MS Urine samples were extracted over Bond Elute Certify

solid-phase extraction columns (Varian, Palo Alto, CA) according to the method of Chen et al. (9) with modifications. Essentially, 5 mL 0.1M monobasic phosphate buffer (pH 6) and 50 pL of internal standard (SKF-525A 50 I~g/mL) were added to 5 mL urine. The extraction columns were conditioned with methanol and water. The sample mixture was added to the column and slowly aspirated. Columns were washed with water and 0.1M acetic acid before being dried with vacuum. Analytes were eluted using acetone/chloroform (1:1) and then 2% ammonium hydroxide in ethyl acetate. Sample eluate was evaporated to 50 pL on a heating block set at 40~ using a steady stream of nitrogen before the addition of the internal standard aminochlorobenzophenone and injec- tion onto the instrument.

Analysis was performed using a Thermoquest GCQ TM

(Thermo Fisher Scientific, Waltham, MA) GC-MS system. One microliter of each sample extract was injected into the injection port set to 225~ Analyte separation was achieved using a Restek RTx| (Restek Corp., Bellefonte, PA). The oven temperature was held at 60~ for 1 rain and then ramped at 20~ to 280~ where it remained for the remainder of each analytical run. Compounds were ionized via electron im- pact ionization. The filament was switched on 4 rain after in- jection and set to 70 eV. The detector was set to positive ion and full scan mode. Scans were acquired from m/z 40 to 500 each second. Peaks were compared to the Pfleger/Maurer/Weber li- brary for identification.

Quantification of prolintane in the patient sample was per- formed against a standard curve (0.5-50 pg/mL, R 2 = 0.992) created by adding known quantities of prolintane to drug-free human urine. Each point in the calibration curve was generated by comparing the total response of the drug to the total re- sponse of the internal standard SKF-525A. The combined con- centration of the metabolites was estimated using the stan- dard curve of the parent drug.

Results

The amphetamine screens of both patients were negative. However, prolintane and metabolites of prolintane were identified in the urine of both patients after solid-phase extraction and analysis by GC-MS. Prolintane and two metabo- lites were retained on the column for 9.98, 18.44, and 18.77 min, respectively (Figure 2); the relative retention times of prolintane and the metabolites to the internal standard SKF- 525A were 0.771, 1.425, and 1.450, respectively. Mass spectral

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Journal o f Analyt ical Toxicology, Vol. 31, September 2007

analysis of prolintane resulted in a base peak at m/z 126 and other significant ions at m/z 55, 91, and 174 (Figure 3). The spectra of each metabolite also included a base peak at m/z 126 and other significant ions at m/z 107 and 96 (data not shown). Negative immunoassay results were obtained at up to 250 pg/mL prolintane with both of the am- phetamine reagents.

Discuss ion

The medical and scientific communities should be made aware of the domestic presence of prolintane because of the

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adverse effects associated with overdose and lack of de- tectability during routine drug screening. The detection of prolintane in both patients' urine by GC-MS emphasizes the importance of comprehensive toxicology analyses in situ- ations of unknown ingestion. Other analytical methods noted to be effective in the detection of prolintane include GC and HPLC with ultraviolet detection at 252, 258, and 264 nm (10). The specific and comprehensive nature of GC-MS is advantageous over immunoassay in cases of unknown ingestion (11,12). The National Academy of Clinical Bio- chemists recommends that GC-MS capability be maintained on a regional level (13), but it is expensive and likely to be avail- able only at major medical centers. Therefore, the diagnostic skills of the primary care physician are essential to the recog-

nition of prolintane overdose. Symptoms of prolintane overdose include

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Overdose with prolintane can result in hallu- cinations, cardiac arrhythmias, respiratory de- pression, and death (14). Symptomatic and supportive care should be provided to all pa- tients suspected of prolintane ingestion. De- contamination with activated charcoal may be effective if administered early after ingestion.

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R e f e r e n c e s

I. A.M. Arria, G.S. Yacoubian, Jr., E. Fost, and E.D. Wish. The pediatric forum: ecstasy use among club rave attendees. Arch. Pediatr. Ado- lesc. Med. 156:295-296 (2002).

2. U.S. Department of Health and Human Ser- vices. Epidemiologic Trends in Drug Abuse, Advance Report. 2006, pp 25-27.

3. J.M. Gaulier, M. Canal, J.L. Pradeille, P. Mar- quet, and G. Lachatre. Nouvelles drogues de rave-parties; ketamine et prolintane. Acta Clin. Belg. Suppl. 1:41-46 (2002).

4. L.E. Hollister and H.K. Gillespie. A new stimu- lant, prolintane hydrochloride, compared with dextroamphetamine in fatigued volunteers. J. Clin. Pharmacol. J. New Drugs 10:103-109 (1970).

5. I. Martinez-Mir, C. Catalan, and V. Palop. Pro- lintane: a "masked" amphetamine. Ann. Phar- macother. 31:256 (1997).

6. R.W. Fuller and H.D. Snoddy. Effects of pro- lintane on 3,4-dihydroxyphenylacetic acid con- centration in rat brain after spiperone treat- ment. Pharmacol. Biochem. Behav. 10: 561-563 (1979).

7. D.A. Cooper. Future Synthetic Drugs of Abuse. U.S. Drug Enforcement Agency, McLean, VA, 2006, p 10.

8. World Anti-Doping Agency. The 2007 Prohib- ited List, International Standard. Montreal, QC, Canada, 2006, p 8.

9. X.H. Chen, J. Wijsbeek, J.P. Franke, and R.A. de

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Journal of Analytical Toxicology, Vol. 31, September 2007

Zeeuw. A single-column procedure on Bond Elut Certify for sys- tematic toxicological analysis of drugs in plasma and urine. J. Forensic Sci. 37:6]-71 (1992).

10. Clarke's Isolation and Identification of Drugs, 2nd ed. The Phar- maceutical Press, London, U.K., 1986, p 931.

11. P.B. Kyle, J.L. Spencer, C.M. Purser, K.C. Eddleman, and A.S. Hume. Suspected pediatric ingestions: effectiveness of im- munoassay screens vs. gas chromatography/mass spectroscopy in the detection of drugs and chemicals. J. ToxicoL Clin. Toxicol. 41: 919-925 (2003).

12. P.B. Kyle, J.L. Spencer, C.M. Purser, and A.S. Hume. Drugs de- tected in suspected pediatric ingestion: a three-year review.

J. Miss. State. Med. Assoc. 45:35-40 (2004). 13. A.H. Wu, C. McKay, L.A. Broussard, R.S. Hoffman, T.C. Kwong,

T.P. Moyer, E.M. Otten, S.L. Welch, and P. Wax. National academy of clinical biochemistry laboratory medicine practice guidelines: recommendations for the use of laboratory tests to sup- port poisoned patients who present to the emergency depart- ment. Clin. Chem. 49" 357-379 (2003).

14. Martindale: The Complete Drug Reference, 33rd ed. Pharma- ceutical Press, London, U.K., 2002, pp 1507, 1514.

Manuscript received March 30, 2007; revision received May 18, 2007.

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