Class of 2005 Abstract / Objectives: To determine whether the quantity of active ingredient and content uniformity of lorazepam and phenytoin manufactured in Mexico is comparable with those manufactured in the United States. Methods: A high-performance liquid chromatography (HPLC) assay based on slightly modified United States Pharmacopoeia- National Formulary (USP-NF) guidelines was used. Relative quantification of the active ingredient was accomplished using the US products as standards. The US products were assumed to contain 100% of the active ingredient. Lorazepam 1mg tablets and phenytoin 100mg capsules were tested using the assays. Results: The quantity of active ingredient in the Mexican lorazepam 1mg tablets were within the acceptable range of the USP-NF guidelines at 100%. The content uniformity was also within the acceptable range of the USP-NF guidelines at 104.6%. The quantity of active ingredient in the Mexican phenytoin 100mg capsules as well as content uniformity were also within the acceptable range of the USP-NF guidelines at 101.6% and 98.2%, respectively. Implications: The results of this study showed that lorazepam and phenytoin manufactured in Mexico were comparable to those manufactured in the US with no significant differences regarding amount of active ingredient and content uniformity.

A high-performance liquid chromatography (HPLC) method with ultraviolet (UV) detection was developed and validated for the quantification of lorazepam in oral solution. The chromatographic conditions include an isocratic separation (25% water / 75% methanol at a flow rate of 0.500 ml/min) on a Waters X=Bridge C18 column (150 x 4.6 mm; 3.5-micron particle size). The method was validated using guidance from the United States Pharmacopeia (USP) chapter, including investigation of system suitability, precision, accuracy, linearity, and specificity. The calibration curves on three non-consecutive days met the linearity criteria R2 >0.99. Each chromatogram for 200 mcg/mL calibration samples, designated as 100% assay level, met system suitability criteria of resolution ≥2.0, tailing factor ≤2.0, column efficiency (theoretical plates) ≥2000, and precision of prior metrics % RSD ≤1.0. Three replicates of each concentration, 150 mcg/mL at 75% assay, 200 mcg/mL at 100% assay, and 250 mcg/mL at 125% assay were assessed for precision and accuracy over 3 days. Precision and accuracy were evaluated and met the inter-day (repeatability) criteria % RSD and % Error ≤ 2% and intra-day (intermediate) criteria % RSD and % Error ≤ 5% at the 75%, 100%, and 125% assay levels. To assess for specificity, 200 mcg/mL samples were assessed for degradation after being subjected to heat (>60°C), oxidation (3% H2O2), acidic (0.1M HCl), and basic (0.1M NaOH) environments. Samples from each condition were evaluated for lorazepam recovery at 0, 24, and 48 hours. Most drug loss was observed with the samples subjected to acidic and oxidative environments, with 14.71% and 13.16% drug loss, respectively after 48 hours. This method was developed to support the 30-day stability investigation of lorazepam oral solution when stored in oral syringes at room and refrigerated temperatures.

The drug lorazepam is a benzodiazepine by class and is used in many healthcare settings as a sedative and anxiolytic. This drug is often found in hospital settings in the dosage form of an oral concentrate, of which patients may receive doses of 0.5 - 1 milliliters. A typical supply of drug product would come in a 30-milliliter bottle requiring protection from light, constant refrigeration, and a beyond use date of 90-days once the bottle is opened, according to package instructions. Aliquoting lorazepam oral solution into syringes allows for higher efficiency facilitated dispensing than as-needed dispensing from a multi-use stock bottle. Preparing individual doses in oral syringes before they are needed may also reduce dosing errors. There is currently no data that supports the practice of storing lorazepam oral solution in syringes, which introduces uncertainty of the product’s safety and efficacy over time. In this study, 2mg/mL lorazepam oral solution was aliquoted into syringes in 1mL doses from 2 multi-dose stock bottles and randomly allocated in an even proportion to be stored in either a room temperature or refrigerated environment. A validated stability-indicating high-performance liquid chromatography method with ultraviolet detection was used to investigate the concentration of lorazepam in the syringe-stored solutions. A fresh calibration curve in the range of 50 – 250 micrograms/mL lorazepam was prepared each day to facilitate quantification. Baseline lorazepam concentrations were measured on the day the study was initiated and designated as 100% recovery samples. Subsequent samples were analyzed from the refrigerated and room temperature syringes in triplicate at time points of 24, 48, and 96 hours and 7, 10, 14, 21, and 28 days. Our data predict that lorazepam can be safely stored in oral syringes at room and refrigerated temperatures for greater than 7 days.

Desenvolveu-se método de alta sensibilidade e especificidade por cromatografia liquida de alta eficiência acoplada a detecção por espectrometria de massas (LC-MS/MS) para quantificação do lorazepam em plasma humano visando aplicação em estudo de bioequivalência entre duas formulações de comprimidos contendo esse fármaco. A preparação das amostras de plasma foi feita por extração líquido-líquido usando hexano:diclorometano (60:40 v/v) como solvente de extração. O padrão interno usado foi o bromazepam. A separação cromatográfica ocorreu utilizando-se coluna analítica modelo Gemini® C18 110 A (150 mm x 4,6 mm; partículas de 5µm). Mistura de metanol e tampão acetato de amônio 10 mM (80:20, v/v), acrescida de 0,1% de ácido fórmico ao final da preparação, foi usada como fase móvel. A interface entre HPLC e MS/MS foi a fonte de ionização por eletrospray (ESI) operando em modo positivo (ES+). O analito e o PI foram monitorados e quantificados através de multiple reaction monitoring (MRM). As transições monitoradas foram m/z 320,69 > 274,96 para o lorazepam e m/z 318,00 > 182,20 para o padrão interno. O método foi validado na faixa de concentração de 0,50 a 80,0 ng/ml em plasma humano. A bioequivalência entre as formulações foi determinada através dos intervalos de confiança 90 % obtidos para as razões dos parâmetros farmacocinéticos Cmax (99% - 114%), AUC0-t (93% - 105%) e AUC0-inf (96% - 107%). Concluiu-se que as duas formulações podem ser administradas de maneira intercambiável sem prejuízo da eficácia terapêutica. / A method of liquid chromatography coupled to mass spectrometric detection (LC-MS/MS) with high sensitivity and specificity was developed to quantify Lorazepam in human plasma. This method was applied in a bioequivalence study between two tablet formulations. The preparation of plasma samples were performed by liquid-liquid extraction using hexanedichloromethane (60:40 v/v) as extraction solvent. The internal standard was bromoazepam. The chromatographic separation was achieved using the Gemini® C18 110A (150 mm x 4.6mm; 5µm particles) analytical column. The mobile phase was prepared from a mixture of methanol and 10mM of ammonium acetate (80:20, v/v), and finally adding 0.1% of formic acid. The HPLC and MS/MS interface was the electrospray ionization source (ESI), operating in positive mode (ESI+). The analyte and internal standard were monitored and quantified through multiple reaction monitoring (MRM). The monitored transitions were m/z 320.69 > 274.96 for lorazepam and m/z 318.00 > 182.20 for the internal standard. The method was validated over the range 0.50 to 80.0 ng/mL in human plasma. The bioequivalence between the two formulations was determined inside the 90% confidence interval for the pharmacokinetic parameters, Cmax (99% - 114%), AUC0-t (93% - 105%) and AUC0-inf (96% - 107%). It was concluded that the two formulations can be administered in an interchangeable manner without losing the therapeutic efficiency.

Desenvolveu-se método de alta sensibilidade e especificidade por cromatografia liquida de alta eficiência acoplada a detecção por espectrometria de massas (LC-MS/MS) para quantificação do lorazepam em plasma humano visando aplicação em estudo de bioequivalência entre duas formulações de comprimidos contendo esse fármaco. A preparação das amostras de plasma foi feita por extração líquido-líquido usando hexano:diclorometano (60:40 v/v) como solvente de extração. O padrão interno usado foi o bromazepam. A separação cromatográfica ocorreu utilizando-se coluna analítica modelo Gemini® C18 110 A (150 mm x 4,6 mm; partículas de 5µm). Mistura de metanol e tampão acetato de amônio 10 mM (80:20, v/v), acrescida de 0,1% de ácido fórmico ao final da preparação, foi usada como fase móvel. A interface entre HPLC e MS/MS foi a fonte de ionização por eletrospray (ESI) operando em modo positivo (ES+). O analito e o PI foram monitorados e quantificados através de multiple reaction monitoring (MRM). As transições monitoradas foram m/z 320,69 > 274,96 para o lorazepam e m/z 318,00 > 182,20 para o padrão interno. O método foi validado na faixa de concentração de 0,50 a 80,0 ng/ml em plasma humano. A bioequivalência entre as formulações foi determinada através dos intervalos de confiança 90 % obtidos para as razões dos parâmetros farmacocinéticos Cmax (99% - 114%), AUC0-t (93% - 105%) e AUC0-inf (96% - 107%). Concluiu-se que as duas formulações podem ser administradas de maneira intercambiável sem prejuízo da eficácia terapêutica. / A method of liquid chromatography coupled to mass spectrometric detection (LC-MS/MS) with high sensitivity and specificity was developed to quantify Lorazepam in human plasma. This method was applied in a bioequivalence study between two tablet formulations. The preparation of plasma samples were performed by liquid-liquid extraction using hexanedichloromethane (60:40 v/v) as extraction solvent. The internal standard was bromoazepam. The chromatographic separation was achieved using the Gemini® C18 110A (150 mm x 4.6mm; 5µm particles) analytical column. The mobile phase was prepared from a mixture of methanol and 10mM of ammonium acetate (80:20, v/v), and finally adding 0.1% of formic acid. The HPLC and MS/MS interface was the electrospray ionization source (ESI), operating in positive mode (ESI+). The analyte and internal standard were monitored and quantified through multiple reaction monitoring (MRM). The monitored transitions were m/z 320.69 > 274.96 for lorazepam and m/z 318.00 > 182.20 for the internal standard. The method was validated over the range 0.50 to 80.0 ng/mL in human plasma. The bioequivalence between the two formulations was determined inside the 90% confidence interval for the pharmacokinetic parameters, Cmax (99% - 114%), AUC0-t (93% - 105%) and AUC0-inf (96% - 107%). It was concluded that the two formulations can be administered in an interchangeable manner without losing the therapeutic efficiency.

La stimulation magnétique transcrânienne (SMT) et la spectroscopie par résonance magnétique (SRM) sont des techniques non-invasives permettant de quantifier l’activité GABAergique et glutamatergique du cerveau. La SMT et la SRM ont plusieurs applications en clinique et en recherche. En effet, ces outils peuvent être utilisés afin de déterminer l’efficacité d’un traitement ou la progression d’un processus pathologique. Cependant, malgré leur utilisation croissante dans le domaine médical, une certaine incertitude demeure quant aux substrats neurochimiques de ces techniques et à la stabilité à long terme des données acquises par SMT et SRM. Donc, dans un premier temps, la stabilité à long terme de plusieurs mesures prises par SMT et par SRM a été étudiée. En second lieu, afin de mieux comprendre quelles composantes du système GABAergique sont ciblées par ces deux techniques, des mesures de SRM et de SMT ont été obtenues après l’administration d’une benzodiazépine, le lorazépam, selon un devis expérimental randomisé, croisé, à double-aveugle et contrôlé par placébo. Deux articles composent cette thèse. Le premier article fait état d’une étude longitudinale, auprès d’adultes en santé, ayant pour but de déterminer la stabilité à long terme des concentrations de GABA et de Glx (glutamate + glutamine) obtenues par SRM ainsi que la stabilité des mesures d’inhibition et de facilitation corticale obtenues par SMT (rMT : seuil moteur au repos, %MSO : pourcentage d’intensité maximale du stimulateur, SICI : inhibition intra-corticale courte, LICI : inhibition intra-corticale longue, ICF : facilitation intra-corticale). Il a été démontré que les niveaux de GABA et de Glx sont stables au cours d’une période de trois mois. Alors que les mesures SMT de seuil moteur au repos, d’excitabilité corticale et de période corticale silencieuse sont stables à travers le temps, l’inhibition corticale à court intervalle et à long intervalle ainsi que la facilitation corticale sont beaucoup plus variables. Le deuxième article vise à comprendre la dissociation dans la sensibilité des mesures de SMT et SRM à refléter différentes facettes de l’activité GABAergique du cortex moteur. L’article porte sur une étude dans laquelle du lorazépam a été administré à des participants adultes en santé selon un devis randomisé, croisé, à double-aveugle et contrôlé par placébo. Des données SRM (GABA et Glx; cortex sensorimoteur et occipital) ainsi que des mesures SMT (cortex moteur) ont été obtenues suivant l’administration de lorazépam (ou de placébo). Il a été démontré que la prise de lorazépam réduisait les niveaux de GABA occipitaux, augmentait l’inhibition corticale et réduisait l’excitabilité du cortex moteur. La prise de médicament n’avait pas d’effet sur les autres mesures obtenues. De plus, il a été trouvé que l’effet du traitement sur l’inhibition corticale dépendait des concentrations endogènes de GABA dans le cortex sensorimoteur; une plus grande concentration de GABA étant prédictive d’une plus grande inhibition corticale suivant la prise de lorazépam. Dans leur ensemble, les résultats provenant des deux articles présentés dans cette thèse permettent de conclure que les mesures SRM des divers neurométabolites sont stables à long terme dans le cortex moteur et pourraient potentiellement servir de marqueurs dans l’évaluation de l’efficacité d’un traitement ou de l’évolution de processus pathologiques. Par contre, bien que certaines mesures SMT soient stables à long terme (rMT, %MSO, CSP), d’autres sont beaucoup plus variables (SICI, LICI, ICF); ainsi, la prudence est conseillée dans l’interprétation de ces mesures lors d’études cliniques. De plus, les effets différents que produit la prise de lorazépam sur les mesures SRM et SMT supportent la théorie selon laquelle les deux techniques n’ont pas les mêmes substrats neurochimiques. En effet, alors que les mesures TMS d’inhibition corticale refléteraient l’activité phasique des récepteurs GABAA, le signal SRM de GABA serait majoritairement intracellulaire et ne représenterait pas la neurotransmission GABAergique. / Transcranial magnetic stimulation (TMS) and magnetic resonance spectroscopy (MRS) are non-invasive techniques that allow the measurement of GABAergic and glutamatergic activity in the brain. TMS and MRS can be used to assess inhibitory and excitatory mechanisms, treatment response or disease presence and progression in vivo. However, despite their growing use in research and medical settings, ambiguity remains regarding their neurochemical substrates and long-term reproducibility. The goal of the present thesis is twofold. First, the long-term stability and reliability of various MRS and TMS measurements, obtained in the motor cortex, was investigated. Second, to better understand which aspects of the GABAergic network are targeted by the two techniques, TMS and MRS measures reflecting cortical inhibition and excitation were obtained following lorazepam administration using a placebo-controlled, double-blind, randomized, crossover design. Two articles comprise this thesis. The first article is a longitudinal assessment of the stability and reliability of MRS-GABA and Glx (glutamate + glutamine) and TMS measures of cortical inhibition and facilitation in the sensorimotor (SMC) cortex of healthy adults. It was determined that MRS-GABA and MRS-Glx are stable over a three-month interval. TMS measures of resting motor threshold (rMT), cortical excitability (% maximum stimulator output; MSO) and cortical silent period (CSP) were also found to be stable and reliable. However, paired-pulse TMS measures such as short-interval cortical inhibition (SICI), long-interval cortical inhibition (LICI) and intracortical facilitation (ICF) had greater variability. The second article aims to understand the differential sensitivity of TMS and MRS with respect to GABAergic activity in the primary motor cortex. It is based on the results and conclusions of a placebo-controlled, double-blind, randomized, crossover study, where benzodiazepine lorazepam was given to healthy adult volunteers. Magnetic resonance spectroscopy (GABA and Glx) was performed in the sensorimotor cortex and occipital cortex (OC). TMS measurements were acquired in the motor cortex only. MRS and TMS measures of cortical inhibition and excitability (rMT, input/output (I/O) curve, SICI, LICI, ICF, CSP) were obtained following lorazepam or placebo administration. Lorazepam was found to decrease occipital GABA concentration, increase motor cortical inhibition and decrease cortical excitability. Lorazepam administration had no effect on other neurometabolites or TMS measurements. The effect of Lorazepam on short-interval cortical inhibition was found to depend on endogenous GABA levels in the SMC; higher GABA concentrations predicted a greater increase in SICI following drug intake. Taken together, the studies presented in this thesis indicate that MRS neurometabolite levels are stable over time and may thus potentially serve as markers for the monitoring of disease progression and treatment response. However, while some TMS measures have good long-term stability (rMT, %MSO, CSP), others are not as reliable nor stable (SICI, LICI, ICF); care must be taken in clinical settings. Furthermore, the differential effects of lorazepam on MRS and TMS measures support the idea that the two techniques probe different aspects of the GABAergic system. Whereas TMS measures of cortical inhibition reflect phasic GABAA receptor activity, MRS-GABA primarily reflects intracellular, non-neurotransmitter metabolic GABA.