Quantitation and Abundance of Xylazine and Xylazine Metabolites in Human Urine and Plasma by LC-MS/MS

Abstract The most common cause of drug overdose fatality in the US involves synthetic opioids such as fentanyl. Recently the Director of the White House Office of National Drug Control Policy designated fentanyl adulterated or associated with xylazine as an emerging threat to the US, and a national response plan will include xylazine testing. Xylazine is a clonidine analog and is not FDA-approved for use in humans but has been increasingly detected in unregulated illicit drugs supplies. Our understanding of xylazine detection, metabolism, and clinical impact on patients, however, is limited. The objectives of this study are to develop a liquid chromatography tandem mass spectrometry (LC-MS/MS) method to detect xylazine and xylazine metabolites in urine and plasma, and to investigate the presence and abundance of xylazine metabolites in remnant urine and plasma samples submitted for clinical testing. This is achieved by first collecting paired urine and serial plasma samples when urine tests positive for xylazine during routine clinical testing. Plasma samples were prepared for LC-MS/MS analysis by protein precipitation with methanol and xylazine-D6 internal standard. Urines were prepared by dilution with xylazine-D6, followed by a hydrolysis with beta-glucuronidase. All experiments were performed using an Aquity HPLC coupled to a Waters TQS-micro triple quadrupole mass spectrometer. LC separation utilized a C18 column with a 4-minute gradient from 2% to 98% mobile phase B (0.1% formic acid and 2mM ammonium acetate in A: water; B: methanol) with a flow rate of 400 μl/min at 50°C. Multiple reaction monitoring for xylazine and 4-OH-xylazine was optimized with commercial standards. Calibration curves for both analytes were prepared from 0.5 – 2,000 ng/mL in plasma, and 5 – 5,000 ng/mL in urine. Product ion scanning was used to detect four additional xylazine metabolites by spectral matching with previously published full scan tandem mass spectra. The highest intensity fragment ions observed in the product ion spectra were used to develop multiple reaction monitoring experiments for four additional xylazine metabolites, previously described as: sulfone-xylazine, oxo-xylazine, OH-sulfone-xylazine, and OH-oxo-xylazine, in 50 remnant urines and 70 individual plasmas. In remnant urines, xylazine concentrations ranged from less than 5 to greater than 5,000 ng/mL. In remnant plasmas, xylazine ranged from less than 0.5 to 158 ng/mL. Previously reported xylazine metabolites were detected in both urine and plasma, and relative peak area ratios were calculated as metabolite-to-xylazine in both matrices. In urine, the highest average peak area ratio (3.1) was observed for sulfone xylazine, after hydrolysis. In plasma, the highest average peak area ratio (1.4) was observed for oxo-xylazine. We were unable to absolutely quantitate either metabolite due to lack of available standards. Future studies include investigation on the association of xylazine exposure and plasma concentrations with clinical presentation and patient outcomes.