title: Fatal doxepin intoxication--suicide or slow gradual intoxication?
abstract: The differentiation of intoxication courses is one of the most difficult challenges for forensic pathologists and toxicologists. The case of a 52-year-old female inpatient of a psychiatric clinic with multiple medications who died from doxepin intoxication is reported. Concentrations of doxepin metabolites and isomers, pharmacokinetic modelling and genotyping of the doxepin-metabolizing cytochrome P450 (CYP) enzymes led to the following conclusion: the lethal doxepin concentration of 2100 ng/mL was more likely to have been reached due to drug interactions and genetic peculiarities leading to a reduction of the metabolic capacity and not by an acute (suicidal) overdose.
authors.affiliation: Institute of Legal Medicine, University Medical Center, Albertstrasse 9, D-79104 Freiburg im Breisgau, Germany. merja.neukamm@uniklinik-freiburg.de
authors.forename: M A
authors.initials: MA
authors.lastname: Neukamm
authors.forename: S
authors.initials: S
authors.lastname: Vogt
authors.forename: M
authors.initials: M
authors.lastname: Hermanns-Clausen
authors.forename: J
authors.initials: J
authors.lastname: Naue
authors.forename: A
authors.initials: A
authors.lastname: Thierauf
authors.forename: V
authors.initials: V
authors.lastname: Auwärter
mesh_terms: D000929:Antidepressive Agents, Tricyclic / Q000097:blood / Q000493:pharmacokinetics* / Q000506:poisoning*; D001189:Aryl Hydrocarbon Hydroxylases / Q000235:genetics; D002853:Chromatography, Liquid; D065731:Cytochrome P-450 CYP2C19; D065729:Cytochrome P-450 CYP2C9; D019389:Cytochrome P-450 CYP2D6 / Q000235:genetics; D004316:Doxepin / Q000097:blood / Q000493:pharmacokinetics* / Q000506:poisoning*; D004347:Drug Interactions; D005260:Female; D053593:Forensic Toxicology; D005838:Genotype; D006778:Hospitals, Psychiatric; D006801:Humans; D008875:Middle Aged; D009154:Mutation; D010597:Pharmacogenetics; D013405:Suicide; D053719:Tandem Mass Spectrometry
chemical_list: D000929:Antidepressive Agents, Tricyclic; D004316:Doxepin; C450260:CYP2C9 protein, human; D065729:Cytochrome P-450 CYP2C9; D001189:Aryl Hydrocarbon Hydroxylases; C045793:CYP2C19 protein, human; D065731:Cytochrome P-450 CYP2C19; D019389:Cytochrome P-450 CYP2D6