Furosemide in indomethacin-treated infants--systematic review and meta-analysis

Association between Furosemide Exposure and Patent Ductus Arteriosus in Hospitalized Infants of Very Low Birth Weight

OBJECTIVE

To evaluate the association between furosemide exposure and patent ductus arteriosus (PDA) in a large, contemporary cohort of hospitalized infants with very low birth weight (VLBW).

STUDY DESIGN

Using the Pediatrix Medical Group Clinical Data Warehouse, we identified all inborn infants of VLBW <37 weeks of gestation discharged from the neonatal intensive care unit after the first postnatal week from 2011 to 2015. We defined PDA as any medical (ibuprofen or indomethacin) or surgical PDA therapy. We collected data up to the day of PDA treatment or postnatal day 18 for infants not diagnosed with PDA. We performed multivariable logistic regression to evaluate the association between PDA and exposure to furosemide.

RESULTS

We included 43 576 infants from 337 neonatal intensive care units, of whom 6675 (15%) underwent PDA treatment. Infants with PDA were more premature and more often exposed to mechanical ventilation and inotropes. Furosemide was prescribed to 4055 (9%) infants. On multivariable regression, exposure to furosemide was associated with decreased odds of PDA treatment (OR 0.72; 95% CI 0.65-0.79). Increasing percentage of days with furosemide exposure was not associated with PDA treatment (OR 1.01; 95% CI 0.97-1.06).

CONCLUSIONS

Furosemide exposure was not associated with increased odds of PDA treatment in hospitalized infants of VLBW. Further studies are needed to characterize the efficacy and safety of furosemide in premature infants.

Prolonged persistent patent ductus arteriosus: potential perdurable anomalies in premature infants

OBJECTIVE

Patent ductus arteriosus (PDA) is a common condition among preterm infants. Controversy exists regarding the risk-benefit ratio of early closure of PDAs by either medical or surgical treatments. On the other hand, potential morbidities associated with no or delayed closure has not been well studied. The objective of the study was to determine if there is an association of prolonged persistent PDA (PP-PDA) with various morbidities in infants ≤28 weeks or 1250 g.

STUDY DESIGN

This matched case-control analysis includes preterm infants with a diagnosis of PDA over a period of 28 months in a single level III center in the USA. The predictive variable was the presence of a PP-PDA (PDA>3 weeks). Cases were infants with PP-PDA and controls were those with PDA but not PP-PDA (two controls for each case). Outcome variables included days on mechanical ventilation and with oxygen treatment, length of hospital stay, bronchopulmonary dysplasia (BPD), retinopathy of prematurity stage III-V (ROP) necrotizing enterocolitis grade II or more (NEC), delayed growth, direct hyperbilirubinemia >4 mg dl(-1) and osteopenia of prematurity. Data was obtained from database collected prospectively and from the review of clinical records when necessary. Statistics included ANOVA, Kaplan-Meier curves and χ (2). Significance was set at P<0.05.

RESULT

PP-PDA was associated with a significant increase in the number of days of mechanical ventilation, oxygen treatment and length of hospital stay, and in the rates of BPD (60% vs 4.5%), NEC (29% vs 5%), ROP (43% vs 5%), direct hyperbilirubinemia (41% vs 3%), osteopenia (44% vs 6%), parenteral nutrition for >40 days (70% vs 21%), tracheostomy during the hospitalization (15% vs 0%) and delayed growth (70% vs 21%), were also significantly higher in babies with PP-PDA.

CONCLUSION

A prolonged exposure to PDA does not seem to be inconsequential for some infants and is associated with an increase prevalence of severe morbidities with potential long lasting effects.

Hepatic and renal toxicities of indomethacin acid, salt form and complexed forms with hydroxypropyl-β-cyclodextrin on Wistar rats after oral administration

Indomethacin (IM), a non-steroidal anti-inflammatory drug, has the capacity to induce hepatic and renal injuries when administrated systemically. The aim of this study is to assess the IM absorption from complexed forms when orally administered to rats, by means of a comparative evaluation of its capacity to induce hepatic and renal injury in different forms, namely IM acid, IM sodium salt or IM complexed with hydroxypropyl-β-cyclodextrin (HP-β-CD), using freeze- and spray-drying methods. A total of 135 Wistar rats weighing 224.4 ± 62.5 g were put into 10 groups. They were allowed free access to water but were maintained on fast for 18 h before the first administration until the end of the experiment. Water and HP-β-CD (control groups) and IM acid form, IM trihydrated-sodium-salt and IM-HP-β-CD spray- and freeze-dried, at normal and toxic doses (test groups), were orally administered once/day for 3 days. Seventy-two hours after the first administration, the animals were sacrificed and a fragment of the liver and one kidney were collected and prepared for histopathological evaluation. Lesion indexes (rated 0/4 for liver and 0/3 for kidney) were developed and the type of injury scored according to the severity of damage. A statistical analysis of the severity and incidence of lesions was carried out. Animals administered with IM complexed forms showed similar hepatic and renal lesions, both in toxic and therapeutic doses, when compared with those observed in animals administered with IM acid or salt forms. This suggests that under the present experimental conditions, IM is equally absorbed from the gastrointestinal tract, independently of the administered IM form.

Patent ductus arteriosus in preterm neonates

Failure of the ductus arteriosus to close within 48-96 hours of postnatal age results in a left to right shunt across the ductus and overloading of the pulmonary circulation. This is more likely to happen in premature neonates with respiratory distress syndrome. Deterioration in the respiratory status on day 3-4 in a ventilated neonate and unexplained metabolic acidosis may be the earliest indicators of a patent ductus arteriosus (PDA). Indomethacin is the main stay of medical management of PDA in preterm neonates. Guidelines for administration of indomethacin have been described in the protocol. Restricted fluid therapy may be beneficial in the prevention of PDA in preterm neonates. Presence of PDA in a term neonate should be investigated to rule out an underlying congenital heart disease.

Patent ductus arteriosus in preterm neonates

Failure of the ductus arteriosus to close within 48-96 hours of postnatal age results in a left to right shunt across the ductus and overloading of the pulmonary circulation. This is more likely to happen in premature neonates with respiratory distress syndrome. Deterioration in the respiratory status on day 3-4 in a ventilated neonate and unexplained metabolic acidosis may be the earliest indicators of a patent ductus arteriosus (PDA). Indomethacin is the main stay of medical management of PDA in preterm neonates. Guidelines for administration of indomethacin have been described in the protocol. Restricted fluid therapy may be beneficial in the prevention of PDA in preterm neonates. Presence of PDA in a term neonate should be investigated to rule out an underlying congenital heart disease.

Furosemide for symptomatic patent ductus arteriosus in indomethacin-treated infants

BACKGROUND

Inhibition of prostaglandin synthesis mediates closure of the ductus arteriosus and renal side effects after indomethacin administration. Because furosemide increases prostaglandin production, it could potentially help prevent indomethacin-related toxicity but also decrease ductal response to indomethacin.

OBJECTIVES

The primary objectives of this review were to assess (1) whether furosemide affects the incidence of failure of ductal closure after indomethacin and that of indomethacin-related toxicity and (2) the effect of furosemide on mid-term and long-term outcome. The secondary objective was to determine whether the effect of furosemide on renal function and water balance depends on prior extracellular volume (assessed by blood urea nitrogen [BUN]/creatinine ratio).

SEARCH STRATEGY

We searched electronic databases (Medline, Embase and Cochrane) and selected abstract books, without language restriction.

SELECTION CRITERIA

We selected studies with (1) random allocation to either indomethacin alone or indomethacin and furosemide and (2) analysis of either short-term risk-benefit ratio of furosemide, mid- or long-term outcome, or the relationship between extracellular volume at study entry and changes in renal function.

DATA COLLECTION AND ANALYSIS

We assessed studies for possible bias and for quality of assessment of ductal patency. We assessed categorical variables using relative risk and absolute risk reduction. We assessed the effects of furosemide on renal function and fluid balance by comparing changes from baseline in the treatment group with those in controls. Subsets were determined a priori based on BUN/creatinine ratio at study entry.

MAIN RESULTS

All 3 studies fulfilling the entry criteria had limitations, including possible or definite bias. There was substantial heterogeneity among studies. Furosemide administration did not significantly increase the risk of failure of ductal closure; however, sample size was insufficient to rule out even a 31% increase. In the subset with initial BUN/creatinine ratio > 20 mg/mg, 2 of 18 patients receiving furosemide could not complete a 3-dose course of indomethacin because of toxicity. Minimal or no information was available about any of the other main outcome variables. Furosemide increased urine output regardless of the initial BUN/creatinine ratio, leading to a 5% weight loss during a 3-dose course, an undesired effect in patients with initial BUN/creatinine ratio > 20 mg/mg. Furosemide increased creatinine clearance only in patients with initial BUN/creatinine ratio <20 mg/mg.

REVIEWER'S CONCLUSIONS

There is not enough evidence to support the administration of furosemide to premature infants treated with indomethacin for symptomatic patent ductus arteriosus. Furosemide appears to be contraindicated in the presence of dehydration in those infants.