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Baud O, Maury L, Lebail F, Ramful D, El Moussawi F, Nicaise C, Zupan-Simunek V, Coursol A, Beuchée A, Bolot P, Andrini P, Mohamed D, Alberti C. Effect of early low-dose hydrocortisone on survival without bronchopulmonary dysplasia in extremely preterm infants (PREMILOC): a double-blind, placebo-controlled, multicentre, randomised trial. Lancet 2016; 387:1827-36. [PMID: 26916176 DOI: 10.1016/s0140-6736(16)00202-6] [Citation(s) in RCA: 207] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia, a major complication of extreme prematurity, has few treatment options. Postnatal steroid use is controversial, but low-dose hydrocortisone might prevent the harmful effects of inflammation on the developing lung. In this study, we aimed to assess whether low-dose hydrocortisone improved survival without bronchopulmonary dysplasia in extremely preterm infants. METHODS In this double-blind, placebo-controlled, randomised trial done at 21 French tertiary-care neonatal intensive care units (NICUs), we randomly assigned (1:1), via a secure study website, extremely preterm infants inborn (born in a maternity ward at the same site as the NICU) at less than 28 weeks of gestation to receive either intravenous low-dose hydrocortisone or placebo during the first 10 postnatal days. Infants randomly assigned to the hydrocortisone group received 1 mg/kg of hydrocortisone hemisuccinate per day divided into two doses per day for 7 days, followed by one dose of 0·5 mg/kg per day for 3 days. Randomisation was stratified by gestational age and all infants were enrolled by 24 h after birth. Study investigators, parents, and patients were masked to treatment allocation. The primary outcome was survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age. We used a sequential analytical design, based on intention to treat, to avoid prolonging the trial after either efficacy or futility had been established. This trial is registered with ClinicalTrial.gov, number NCT00623740. FINDINGS 1072 neonates were screened between May 25, 2008, and Jan 31, 2014, of which 523 were randomly assigned (256 hydrocortisone, 267 placebo). 255 infants on hydrocortisone and 266 on placebo were included in analyses after parents withdrew consent for one child in each group. Of the 255 infants assigned to hydrocortisone, 153 (60%) survived without bronchopulmonary dysplasia, compared with 136 (51%) of 266 infants assigned to placebo (odds ratio [OR] adjusted for gestational age group and interim analyses 1·48, 95% CI 1·02-2·16, p=0·04). The number of patients needed to treat to gain one bronchopulmonary dysplasia-free survival was 12 (95% CI 6-200). Sepsis rate was not significantly different in the study population as a whole, but subgroup analyses showed a higher rate only in infants born at 24-25 weeks gestational age who were treated with hydrocortisone (30 [40%] of 83 vs 21 [23%] of 90 infants; sub-hazard ratio 1·87, 95% CI 1·09-3·21, p=0·02). Other potential adverse events, including notably gastrointestinal perforation, did not differ significantly between groups. INTERPRETATION In extremely preterm infants, the rate of survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age was significantly increased by prophylactic low-dose hydrocortisone. This strategy, based on a physiological rationale, could lead to substantial improvements in the management of the most premature neonates. FUNDING Assistance Publique-Hôpitaux de Paris.
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Affiliation(s)
- Olivier Baud
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, INSERM U1141, Paris, France.
| | - Laure Maury
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, INSERM U1141, Paris, France
| | - Florence Lebail
- Neonatal Intensive Care Unit, Centre Hospitalier Corbeil-Essonnes, Sud Francilien, France
| | - Duksha Ramful
- Neonatal and Pediatric Intensive Care Unit, CHR Saint-Denis, La Réunion, France
| | - Fatima El Moussawi
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Poissy, Poissy, France
| | - Claire Nicaise
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire Hôpital Nord, Marseille, France
| | - Véronique Zupan-Simunek
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Antoine Béclère, Paris, France
| | - Anne Coursol
- Neonatal intensive care unit, Centre Hospitalier de Pontoise, France
| | - Alain Beuchée
- Neonatal Intensive Care Unit, Centre Hospitalier Universitaire Rennes, France
| | - Pascal Bolot
- Neonatal Intensive Care Unit, Centre Hospitalier de Saint-Denis, France
| | - Pierre Andrini
- Neonatal Intensive Care Unit, Centre Hospitalier Universitaire Grenoble, France
| | - Damir Mohamed
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, Université Paris Diderot, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
| | - Corinne Alberti
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, Université Paris Diderot, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
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Ben Said M, Hays S, Loys CM, Coletto L, Godbert I, Picaud JC. Postnatal steroids in extremely low birth weight infants: betamethasone or hydrocortisone? Acta Paediatr 2013; 102:689-94. [PMID: 23551291 DOI: 10.1111/apa.12255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Revised: 03/14/2013] [Accepted: 03/27/2013] [Indexed: 11/29/2022]
Abstract
AIM To compare the efficacy and tolerance of betamethasone (BTM) and hydrocortisone (HC) in weaning extremely low birth weight (ELBW) infants with bronchopulmonary dysplasia (BPD) from the ventilator. METHODS Monocentric, retrospective, cohort analysis based on prospective, standardized collection of data between 2005 and 2011 in ELBW receiving postnatal steroids (PS) after the second week of life. We used BTM for the first 4 years, and thereafter HC. We compared extubation rates, growth, glycaemia and blood pressure. RESULTS Sixty-seven infants received PS: 35 BTM and 32 HC. Most infants (83% BTM vs. 72% HC) were extubated during treatment (p = 0.281). During PS, the need for insulin was similar. Mean arterial blood pressure was similar at day 3 of PS, but was significantly lower in infants treated by BTM 30 days after the end of treatment. The z-scores for body weight and head circumference indicated significantly greater loss in BTM than HC group. This persisted only for body weight after adjustment for differences in energy intake and corticosteroid dose. CONCLUSION Our study suggests that HC may be as efficient as BTM in facilitating the extubation of ELBW infants, without short-term adverse effects. Blood pressure monitoring and investigation of long-term neurodevelopment are nevertheless needed.
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Affiliation(s)
| | | | | | | | - Isabelle Godbert
- Neonatology; University Hospital Croix Rousse; Hospices Civils de Lyon; Lyon; France
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