EtG Quantification in Hair and Different Reference Cut-Offs in Relation to Various Pathologies: A Scoping Review

Title: EtG quantification in hair and different reference cut-offs in relation to various pathologies: a review Authors: Triolo Valentina1; Roberto Buscemi2; Gioè Simona1; Spanò Mario1-2; Marija Čaplinskiene; Argo Antonina1-2. Author Affiliations: 1Policlinic Hospital, AOUP “P. Giaccone”, 2University of Palermo, Italy. 3State Forensic Medicine Service, Mykolas Romeris University, Vilnius, Lithuania. Abstract: The purpose of this article is to describe, through accurate bibliographic research, the main and most frequent pathological conditions that may interfere with EtG quantification in hair and verify whether different reference cut-offs in relation to various pathologies have been identified in scientific literature. In fact, in-depth knowledge of these pathologies would allow a more appropriate interpretation of obtained data and rule out false positives or false negatives, with special attention to reported abstinence cases. Checking and quantifying chronic alcohol consumption is important for forensic and clinical purposes, since it affects possible lawsuits and/or care decisions concerning a person with suspicion chronic alcohol intake. It has implications in workplace, e.g. suspension of driver’s or pilot’s license, in childcare activities, or in care settings such as insertion or removal from liver transplantation’s waiting lists etc.. Furthermore, from a clinical point of view, monitoring of alcohol withdrawal in alcohol-dependent patients can affect the evaluation of treatments’ effect1. Markers are required to identifying and quantifying alcohol consumption to monitor alcohol abstinence /consumption. These markers should have the following characteristics: 1. Differentiate between “at-risk” drinkers, “non-risk” drinkers and subjects in withdrawal phase; 2. Detect alcohol consumption/abstinence over a long period of time (i.e., after complete alcohol elimination from the body)2. Directs and indirect markers are available. However, some of these show low specificity and sensitivity for detecting alcohol consumption, although they are widely available and relatively inexpensive. For this reason, some Authors proposed to combine them to ensure greater specificity. Since the 2000s ethyl glucuronide (EtG) has been identified as an excellent direct-type reference marker. EtG is a non-volatile, nonoxidative, hydrophilic, and stable ethanol phase II metabolite, with a molecular weight of 222 g/mol. This metabolite is produced through ethanol glucuronidation by UDP-glucurontransferase, by adding a glucuronic acid moiety to the ethanol molecule3. EtG can be extracted in different biological matrices: blood and urine samples (which only allow alcohol detection in short period), or keratin matrices, such as hair and nails. Therefore, besides good sensitivity and specificity, a big advantage of this marker is to verify chronic alcohol intake over a long period of time, which can range from months to years depending on samples length, through its quantification in keratin matrices (mostly hair). Unfortunately, many of these markers, including EtG, can undergo alterations due to various factors: 1. Intrinsic factors, e.g., gender, age, comorbidities that aren’t related to alcohol consumption which increase enzyme levels; 2. Extrinsic factors, e.g., cosmetic treatment and/or hair hygiene etc. In EtG case, the detection of its concentrations in hair depends on time to exposure and concentrations to blood EtG; in turn, blood EtG concentration is strongly influenced by individual metabolism. Consequently, all pathological alterations that affect ethanol metabolism must be considered potentially as confounding factors on hair EtG concentration and, therefore, the final data, used for both forensic and clinical purposes, must be interpreted with great caution. According to scientific literature, the main and most frequent pathologies that can influence EtG concentration in hair are liver and kidney diseases, and diabetes. In example, UDP-glucuronosyltransferase (or UGTs, enzyme responsible for the biosynthesis of saccharides) alteration, typical of some liver disease such as Gilbert’s syndrome, causes alterations on hair EtG levels4. References 1. F. Pragst, M. Rothe. B. Moench, M. Hastedt, S. Herre, D. Simmert, Combined use of fatty acid ethyl esters and ethyl glucoronide in hair for diagnosis of alcohol abuse: Interpretation and advantages. Forensic Sci. Int. 196 (2010) 101-110 2. H. Andresen-Streichert, G. von Rothkirch, E. 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The article will describe pathological conditions that may interfere with EtG quantification in hair and reference cut-offs in relation to various pathologies.