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Insulin aspart (NovoRapid®, NovoMix®, Novolog® and Fiasp®) is a fast-acting analog of human insulin, indicated in the treatment of type I and II diabetes. It is administered before meals to mimic the physiological insulin secretion that follows a rise in blood glucose. Its misuse for the purposes of suicide and murder and in the context of factitious order has often been described. In forensic medicine, the identification of insulin in biological samples has always been complex. In this paper, we present a case of suicide of a 64-year-old man who died after the injection of insulin aspart. He was suffering from terminal lung cancer and left a letter explaining the reasons for his suicide. Four empty NovoRapid® pens were found near the body. Body examination was unremarkable, and the femoral blood was collected in two dry Vacutainer™ tubes (red cap) and two sodium fluoride (NaF) tubes (gray cap). A liquid chromatography coupled to high-resolution mass spectrometry method was used to identify and discriminate insulin aspart from human insulin after immunopurification in the blood samples and in the pens. Blood specimens tested positive for insulin aspart with the concentrations of 36 and 37 ng/mL in dry tubes and 58 and 71 ng/mL in tubes containing NaF when tested ∼3 weeks after the collection of the specimens. The contents of the pens also matched with insulin aspart. The stability of insulin in blood is a critical point in the interpretation of the concentrations due to their rapid decrease caused by the activity of proteases in blood. During a degradation study implemented to compare three preservatives and dry tubes, suitable insulin aspart stability was observed with disodium salt of ethylenediaminetetracetic acid and NaF. Given that NaF is standard in forensic toxicology for measuring blood alcohol concentrations, the authors suggest its use for blood collection when insulin intoxication is suspected.

A 29-year-old man with no previous medical history was found dead at home. Anabolic products (tablets and oily solutions) and syringes were found at the scene. The man was known to train regularly at a fitness club and to use anabolic drugs. Following an unremarkable autopsy with normal histology, toxicological analyses were requested by the local prosecutor to provide further information. Blood, head hair (5 cm, black), body hair (axillary and leg) and toe and finger nail clippings were submitted to liquid and gas chromatography coupled to tandem mass spectrometry (LC and GC–MS-MS) methods to test for anabolic steroids. Blood tested positive for testosterone (4 ng/mL), boldenone (26 ng/mL), stanozolol (3 ng/mL) and trenbolone (

Resume Si la conquete de l’espace a marque la fin du millenaire precedant, la decouverte du monde aquatique est l’activite en plein essor depuis le debut des annees 2000. Au-dela de l’aspect economique du fait d’une richesse encore peu exploitee tant pour l’alimentation que pour les minerais, les mers et oceans sont des lieux fascinants qui attirent de plus en plus, a la surface (navigation) et sous l’eau (apnee, plongee). Ainsi, la plongee est devenue en quelques annees le sport incontournable a pratiquer. La notion de plongee loisir, developpee par l’organisme americain PADI (Professional Association of Diving Instructors), inclut des exigences precises en matiere de limites, de formation et d’equipement. Pour l’homme, il n’est pas possible de respirer sous l’eau sans un materiel adapte, qui doit aussi tenir compte des conditions environnementales, en particulier du froid. Du fait d’un nombre croissant de plongeurs certifies dans tous les pays du monde, il n’est pas surprenant que certains d’entre eux souffrent de pathologies diverses pendant leur activite. Il existe donc, pour la plongee, un certain nombre de contre-indications definitives, comme l’insuffisance cardiaque ou respiratoire, l’epilepsie ou des contre-indications temporaires. Parmi cette derniere categorie, la consommation de nombreux medicaments est repertorie comme a risque, comme les s-bloquants, les anti-arythmiques, certains antidiabetiques ou encore les anxiolytiques, les neuroleptiques et les antidepresseurs. Les auteurs rapportent un accident fatal de plongee chez une pratiquante reguliere (niveau 3) ou l’expertise toxicologique a mis en evidence du citalopram, un antidepresseur de type inhibiteur de la recapture de la serotonine, dose a 66 ng/mL, soit une concentration therapeutique. Une revue de la litterature, basee sur les bibliotheques classiques (PubMed, Web of science, Scopus) les sites de federations de plongee et les assureurs specifiques (DAN, AquaMed) a mis en evidence une pauvrete de l’information disponible, alors meme que les antidepresseurs, surtout de nouvelle generation, sont tres largement prescrits a la population generale.

Summary Selective androgen receptor modulators (SARMs) are a class of drugs presenting identical anabolic properties to usual anabolic steroids (testosterone, stanozolol, nandrolone…) in addition to marked reduced androgenic effects. These drugs have emerged in the doping area within the early 2000s. Ligandrol, ostarine, RAD-140 and andarine are the most popular agents belonging to this class. According to the world anti-doping agency (WADA) prohibited list, SARMs are prohibited at all times (i.e. in and out-of-competition) and are listed under the section S1.2 (other anabolic agents), a section that also contains clenbuterol. The compilation of the WADA testing figures reports from 2015 to 2019 has indicated a regular increase of adverse analytical findings (AAF) due to SARMs, particularly with ostarine and ligandrol. The implementation of highly sensitive chromatographic anti-doping analyses has induced high-profile challenges of anti-doping rules violations as athletes have claimed in numerous occasions that contamination was the reason for their AAF. As a result, hair tests were presented in order to establish the circumstances of these AAF. In case of an adverse analytical finding, hair testing can be a complement to document the claim of the athlete but of course, the result should not be considered as an alternative to urinalysis. This is because a negative hair result cannot exclude the use of the detected drug and cannot overrule the urine result. A review of the scientific literature, using the key words “SARMs” and “hair” has indicated that only 7 papers were published on this topic, including 3 dealing with equine hair. Although literature seems very limited, there is an increasing request for hair tests, which as prompted our laboratory to develop screening methods. Drugs are extracted from hair after decontamination under mild alkaline condition and submitted to LC-MS/MS and LC-HRMS assays. In this review, several original cases are provided, and the challenges of interpreting these findings are highlighted in light of the lack of controlled studies in the literature.

Insulin aspart (Novorapid ®, NovoMix®, Novolog® and Fiasp®) is a fast-acting analog of human insulin, indicated in the treatment of type I and II diabetes. It is administered before meals to mimic the physiological insulin secretion that follows a rise in blood glucose. Its misuse for the purposes of suicide, murder and in the context of factitious order has often been described. In forensic medicine, the identification of insulin in biological samples has always been complex. In this paper, we present a case of suicide of a 64-year-old man who died after the injection of insulin aspart. He was suffering from terminal lung cancer and left a letter explaining the reasons of his suicide. Four empty Novorapid® pens were found near the body. Body examination was unremarkable and femoral blood was collected in 2 dry Vacutainer tubes (red cap) and 2 sodium fluoride tubed (grey cap). A LC-HRMS method was used to identify and discriminate aspart insulin from human insulin after immunopurification in the blood samples and in the pens. Blood aspart insulin tested positive at 36 and 37 ng/mL in dry tubes, and at 58 and 71 ng/mL in tubes containing sodium fluoride when tested about 3 weeks after collection of the specimens. The contents of the pens also matched with insulin aspart.The stability of insulin in blood is a critical point in the interpretation of the concentrations due to their rapid decrease caused by the activity of proteases in blood. During a degradation study implemented to compare 3 preservatives and dry tubes, suitable insulin aspart stability was observed with EDTA and NaF. Given NaF is standard in forensic toxicology for measuring blood alcohol concentrations, the authors suggest its use for blood collection when insulin intoxication is suspected.

A 29-year-old man with no previous medical history was found dead at home. Anabolic products (tablets and oily solutions) and syringes were found at the scene. The man was known to train regularly at a fitness club and to use anabolic drugs. Following an unremarkable autopsy with normal histology, toxicological analyses were requested by the local prosecutor to provide further information. Blood, head hair (5 cm, black), body hair (axillary and leg), and toe and finger nail clippings were submitted to LC and GC-MS-MS methods to test for anabolic steroids. Blood tested positive for testosterone (4 ng/mL), boldenone (26 ng/mL), stanozolol (3 ng/mL) and trenbolone (1 ng/mL). Segmental head hair tests (2 x 2.5 cm) revealed a repeated consumption of testosterone (65-72 pg/mg), testosterone propionate (930-691 pg/mg), testosterone isocaproate (79 pg/mg-5 pg/mg), nandrolone decanoate (202-64 pg/mg), boldenone (16 pg/mg), stanozolol (575-670 pg/mg), trenbolone (4 pg/mg-not detected), drostanolone (112-30 pg/mg), drostanolone enanthate (26-5 pg/mg) and drostanolone propionate (15-4 pg/mg). In addition to the substances identified in head hair, testosterone decanoate, testosterone cypionate and nandrolone were identified in both body hair and nails. The experts concluded that the manner of death can be listed as toxic, due to massive repetitive use of anabolic steroids during the previous months. For anabolic agents, blood does not seem to be the best matrix to document a fatal intoxication. Indeed, these products are toxics when long term abused and are known to cause cardiac, hepatic and renal diseases. When compared to blood, hair and nails have a much larger window of detection. Therefore, keratinous matrices seems to be the best approach to test for anabolic steroids when a sudden death is observed in a context of possible abuse of steroids.

Fingerprints are invisible traces that result from a deposition of sweat and sebum present on the papillary ridges. As sweat and sebum contain drugs, fingerprints are promising since collection is rapid, non-invasive and difficult to falsify. Very limited data are available in the literature, and therefore, it seems opportune to study the transfer of xenobiotics onto the items taken in hand via the fingerprints. Two studies were implemented using the ballpoint pen as a model. The objective of the first study was to compare the nicotine concentrations found on the pens of three smokers and three non-smokers. Five pens, belonging to each subject and used regularly, were rubbed with a cotton swab dipped in methanol and analyzed by liquid chromatography coupled with tandem mass spectrometry (LC–MS-MS). The second study was to analyze the transfer via fingerprints of four volunteers, after administration of 30 mg of codeine. The objective was to determine the feasibility of this study and the time corresponding to the highest concentration of codeine. Over a 24-h period, new pens were handled for 5 min by the four volunteers, rubbed with a cotton swab dipped in methanol, and then analyzed by LC–MS-MS. The nicotine study showed a major difference between the nicotine concentrations obtained from smokers (between 6 and 276 ng/pen) and non-smokers (between 2 and 4 ng/pen). After administration of 30 mg of codeine, the analysis of the pens of the four volunteers allowed to demonstrate the presence of codeine up to 24 h between 9 and 544 pg/pen. Normal hygiene practices did not influence the final result. The highest concentration was observed after 2 h. Morphine was also detected (between 19 and 33 pg/pen). These preliminary results should be considered a demonstration of the interest of fingerprints testing to document drug exposure.

Oral antidiabetics are the drugs used to control blood sugar in diabetic subjects. The greatest risk of using these drugs is hypoglycaemia, which can be fatal if managed inappropriately. The diagnosis of hypoglycemia may be simple in diabetic subjects but can become a challenge in subjects with no history of exposure to these drugs. The major interest of testing for these compounds in hair is in the case of unexpected hypoglycaemias, as it enables discrimination between hypoglycaemias caused by antidiabetics and other reasons (e.g. insulinoma). Therefore it is important for a toxicology laboratory to screen for antidiabetics in hair due to the large window of detection this matrix allows associated to its long stability over time. In this study, a method has been developed and validated using liquid-chromatography coupled to tandem mass spectrometry for the analysis of 13 oral antidiabetics in hair. After addition of three different internal standards (hydroxy-tolbutamide-d9 for sulfonylureas, repaglinide-ethyl-d5 for glinides and vildagliptin-d3 for gliptins) and incubation in an ultrasonic bath in methanol, the hair was dissolved in NaOH and then subjected to liquid-liquid extraction. The validation procedure demonstrated an acceptable linearity for all compounds between 1 and 50,000 pg/mg. LOD and LOQ were between 0.5 and 5 pg/mg and 1-10 pg/mg respectively. Repeatability and reproducibility were below 20 % at two concentrations for all the analytes. The method was successfully applied to the hair of 18 diabetic patients under treatment of oral antidiabetics. The hair tested positive for gliclazide (3-21,400 pg/mg), sitagliptin (1.4-1.8 pg/mg), vildagliptin (3.3 - 1,740 pg/mg) and repaglinide (14.1 pg/mg).

Tizanidine, an imidazoline derivative close to clonidine, is a central alpha-2 adrenergic receptor agonist. Therapeutically, the drug is used as a muscle relaxant under the trade names Sirdalud™ or Zanaflex™. The drug is not prohibited by the World Anti-Doping Agency but, for therapeutic purposes, can only be obtained via a nominative temporary use authorization. The French public health police requested the laboratory to test for tizanidine in head hair specimens collected from international racing cyclists. Using Liquid chromatography-tandem mass spectrometry (LC/MS-MS) and confirmation by liquid chromatography-high-resolution mass spectrometry (LC/HRMS), after pH 9.5 borate buffer overnight incubation of 20 mg and subsequent solvents extraction, tizanidine was identified in the hair of three athletes at 1.1, 3.7, and 11.1 pg/mg. This is the first evidence that tizanidine is incorporated in human hair. However, it was not possible to interpret the data in terms of doses and frequency of use due to a lack of controlled study.

The selective androgen receptor modulators are a recent class of anabolic agents, used to improve athletic performance. Among these molecules, there is (2 S)-N-(4-cyano-3-trifluoromethylphenyl)- 3-(3-fluoro-4-chlorophenoxyl)2-hydroxy-2-methyl-propanamide, commonly known as S-23. This molecule appeared very recently on the doping market. As a result, very few data are available in the literature, and nothing has been published about long-term effects of S-23. The authors focused on the detection of S-23 and its metabolites in human urine, following a single oral administration of approx. 8 mg to a volunteer, using standard ultra-performance liquid chromatography-triple quadrupole-mass spectrometry (UPLC-MS/MS), and ultra-performance liquid chromatography-quadrupole time of flight-mass spectrometry (UPLC-Q-TOF-MS). To the best of the authors knowledge, this seems to be the first study ever achieved on S-23. In vitro experiment was performed, using human liver microsomes, in order to investigate the potential CYP- and UGT-dependent S-23 metabolites. Four metabolites were produced, which were identified as hydroxy-S-23 (C