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Wu Y, Allegaert K, Flint RB, Goulooze SC, Välitalo PAJ, de Hoog M, Mulla H, Sherwin CMT, Simons SHP, Krekels EHJ, Knibbe CAJ, Völler S. When will the Glomerular Filtration Rate in Former Preterm Neonates Catch up with Their Term Peers? Pharm Res 2024; 41:637-649. [PMID: 38472610 PMCID: PMC11024008 DOI: 10.1007/s11095-024-03677-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/10/2024] [Indexed: 03/14/2024]
Abstract
AIMS Whether and when glomerular filtration rate (GFR) in preterms catches up with term peers is unknown. This study aims to develop a GFR maturation model for (pre)term-born individuals from birth to 18 years of age. Secondarily, the function is applied to data of different renally excreted drugs. METHODS We combined published inulin clearance values and serum creatinine (Scr) concentrations in (pre)term born individuals throughout childhood. Inulin clearance was assumed to be equal to GFR, and Scr to reflect creatinine synthesis rate/GFR. We developed a GFR function consisting of GFRbirth (GFR at birth), and an Emax model dependent on PNA (with GFRmax, PNA50 (PNA at which half ofGFR max is reached) and Hill coefficient). The final GFR model was applied to predict gentamicin, tobramycin and vancomycin concentrations. RESULT In the GFR model, GFRbirth varied with birthweight linearly while in the PNA-based Emax equation, GA was the best covariate for PNA50, and current weight for GFRmax. The final model showed that for a child born at 26 weeks GA, absolute GFR is 18%, 63%, 80%, 92% and 96% of the GFR of a child born at 40 weeks GA at 1 month, 6 months, 1 year, 3 years and 12 years, respectively. PopPK models with the GFR maturation equations predicted concentrations of renally cleared antibiotics across (pre)term-born neonates until 18 years well. CONCLUSIONS GFR of preterm individuals catches up with term peers at around three years of age, implying reduced dosages of renally cleared drugs should be considered below this age.
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Affiliation(s)
- Yunjiao Wu
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sebastiaan C Goulooze
- Leiden Experts On Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Pyry A J Välitalo
- School of Pharmacy, University of Eastern Finland, Yliopistonranta 1 C, 70210, Kuopio, Finland
- Finnish Medicines Agency, Hallituskatu 12-14, 70100, Kuopio, Finland
| | - Matthijs de Hoog
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hussain Mulla
- Department of Pharmacy, University Hospitals of Leicester, Glenfield Hospital, Leicester, LE39QP, England
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine/Dayton Children's Hospital, One Children's Plaza, Dayton, OH, USA
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elke H J Krekels
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands
- Certara Inc, Princeton, NJ, USA
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Swantje Völler
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands.
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.
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2
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Alsmadi MM. Evaluating the Pharmacokinetics of Fentanyl in the Brain Extracellular Fluid, Saliva, Urine, and Plasma of Newborns from Transplacental Exposure from Parturient Mothers Dosed with Epidural Fentanyl Utilizing PBPK Modeling. Eur J Drug Metab Pharmacokinet 2023; 48:567-586. [PMID: 37563443 DOI: 10.1007/s13318-023-00842-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Fentanyl can mitigate the mother and newborn complications resulting from labor pain. However, fentanyl shows a narrow therapeutic index between its respiratory depressive and analgesic effects. Thus, prenatally acquired high fentanyl levels in the newborn brain extracellular fluid (bECF) may induce respiratory depression which requires therapeutic drug monitoring (TDM). TDM using saliva and urine in newborns can reduce the possibility of infections and distress associated with TDM using blood. The objective of this study was to develop a physiologically based pharmacokinetic (PBPK) model to predict fentanyl concentrations in different newborn tissues due to intrauterine exposure. METHODS A fentanyl PBPK model in adults after intravenous and epidural administration was built, validated, and scaled to pregnancy and newborn populations. The dose that the newborn received transplacentally at birth was calculated using the pregnancy model. Then, the newborn bECF, saliva, plasma, and urine concentrations after such a dose were predicted using the newborn PBPK model. RESULTS After a maternal epidural dose of fentanyl 245 µg, the predicted newborn plasma and bECF levels were below the toxicity thresholds. Furthermore, the salivary threshold levels in newborns for fentanyl analgesic and respiratory depression effects were estimated to be 0.39 and 14.7-18.2 ng/ml, respectively. CONCLUSION The salivary TDM of fentanyl in newborns can be useful in newborns exposed to intrauterine exposure from parturient females dosed with epidural fentanyl. However, newborn-specific values of µ-opioid receptors IC50 for respiratory depression are needed.
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Affiliation(s)
- Mo'tasem M Alsmadi
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.
- Nanotechnology Institute, Jordan University of Science and Technology, Irbid, Jordan.
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3
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Lugli L, Garetti E, Goffredo BM, Candia F, Crestani S, Spada C, Guidotti I, Bedetti L, Miselli F, Della Casa EM, Roversi MF, Simeoli R, Cairoli S, Merazzi D, Lago P, Iughetti L, Berardi A. Continuous Fentanyl Infusion in Newborns with Hypoxic-Ischemic Encephalopathy Treated with Therapeutic Hypothermia: Background, Aims, and Study Protocol for Time-Concentration Profiles. Biomedicines 2023; 11:2395. [PMID: 37760835 PMCID: PMC10525845 DOI: 10.3390/biomedicines11092395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Therapeutic hypothermia (TH) is the standard of care for newborns with moderate to severe hypoxic-ischemic encephalopathy (HIE). Discomfort and pain during treatment are common and may affect the therapeutic efficacy of TH. Opioid sedation and analgesia (SA) are generally used in clinical practice, and fentanyl is one of the most frequently administered drugs. However, although fentanyl's pharmacokinetics (PKs) may be altered by hypothermic treatment, the PK behavior of this opioid drug in cooled newborns with HIE has been poorly investigated. The aim of this phase 1 study protocol (Trial ID: FentanylTH; EUDRACT number: 2020-000836-23) is to evaluate the fentanyl time-concentration profiles of full-term newborns with HIE who have been treated with TH. Newborns undergoing TH receive a standard fentanyl regimen (2 mcg/Kg of fentanyl as a loading dose, followed by a continuous infusion-1 mcg/kg/h-during the 72 h of TH and subsequent rewarming). Fentanyl plasma concentrations before bolus administration, at the end of the loading dose, and 24-48-72-96 h after infusion are measured. The median, maximum, and minimum plasma concentrations, together with drug clearance, are determined. This study will explore the fentanyl time-concentration profiles of cooled, full-term newborns with HIE, thereby helping to optimize the fentanyl SA dosing regimen during TH.
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Affiliation(s)
- Licia Lugli
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Elisabetta Garetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Francesco Candia
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Sara Crestani
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Caterina Spada
- Neonatal Unit, Women’s and Children’s Department, Bufalini Hospital of Cesena, 47521 Cesena, Italy;
| | - Isotta Guidotti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Luca Bedetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Francesca Miselli
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy;
| | - Elisa Muttini Della Casa
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Maria Federica Roversi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Daniele Merazzi
- Neonatal Unit, Women’s and Children’s Department, Valduce Hospital, 22100 Como, Italy;
| | - Paola Lago
- Neonatal Intensive Care Unit, Women’s and Children’s Department, Ca’ Foncello Hospital, 31100 Treviso, Italy;
| | - Lorenzo Iughetti
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Alberto Berardi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
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4
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Leopoldino RWD, Marques DP, Rocha LC, Fernandes FEM, Oliveira AG, Martins RR. Temporal profile of adverse drug reactions and associated clinical factors: a prospective observational study in a neonatal intensive care unit. BMJ Open 2023; 13:e073304. [PMID: 37553191 PMCID: PMC10414078 DOI: 10.1136/bmjopen-2023-073304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE Although adverse drug reactions (ADRs) are quite common in hospitalised neonates, pharmacovigilance activities in this public are still incipient. This study aims to characterise ADRs in neonates in a neonatal intensive care unit (NICU), identifying causative drugs, temporal profile and associated factors. DESIGN Prospective observational study. SETTING NICU of a public maternity hospital in Natal/Brazil. PARTICIPANTS All neonates admitted to the NICU for more than 24 hours and using at least one medication were followed up during the time of hospitalisation. PRIMARY OUTCOME MEASURES Incidence rate and risk factors for ADRs. The ADRs were detected by an active search in electronic medical records and analysis of spontaneous reports in the hospital pharmacovigilance system. RESULTS Six hundred neonates were included in the study, where 118 neonates had a total of 186 ADRs. The prevalence of ADRs at the NICU was 19.7% (95% CI 16.7% to 23.0%). The most common ADRs were tachycardia (30.6%), polyuria (9.1%) and hypokalaemia (8.6%). Tachycardia (peak incidence rate: 57.1 ADR/1000 neonates) and hyperthermia (19.1 ADR/1000 neonates) predominated during the first 5 days of hospitalisation. The incidence rate of polyuria and hypokalaemia increased markedly after the 20th day, with both reaching a peak of 120.0 ADR/1000 neonates. Longer hospitalisation time (OR 0.018, 95% CI 0.007 to 0.029; p<0.01) and number of prescribed drugs (OR 0.127, 95% CI 0.075 to 0.178; p<0.01) were factors associated with ADRs. CONCLUSION ADRs are very common in NICU, with tachycardia and hyperthermia predominant in the first week of hospitalisation and polyuria and hypokalaemia from the third week onwards.
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Affiliation(s)
- Ramon Weyler Duarte Leopoldino
- Graduate Program of Pharmaceutical Science, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Daniel Paiva Marques
- Department of Pharmacy, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Luan Carvalho Rocha
- Department of Pharmacy, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Flavia Evelyn Medeiros Fernandes
- School Maternity Januário Cicco (MEJC/EBSERH), Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Antonio Gouveia Oliveira
- Graduate Program of Pharmaceutical Science, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
- Department of Pharmacy, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Rand Randall Martins
- Graduate Program of Pharmaceutical Science, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
- Department of Pharmacy, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
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5
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Bäcke P, Bruschettini M, Blomqvist YT, Olsson E. Interventions for the management of Pain and Sedation in Newborns undergoing Therapeutic hypothermia for hypoxic-ischemic encephalopathy (IPSNUT): protocol of a systematic review. Syst Rev 2022; 11:101. [PMID: 35606836 PMCID: PMC9128112 DOI: 10.1186/s13643-022-01982-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical research has shown that therapeutic hypothermia after neonatal hypoxic-ischemic injury improves survival without disability. There is no consensus regarding pain relief or sedation during therapeutic hypothermia in newborns; however, therapeutic hypothermia seems to be associated with pain and stress, and adequate analgesia and sedation are central to maximize the effect of therapeutic hypothermia. Pain needs to be adequately managed in all patients, especially the newborn infant due to the potential short- and long-term negative effects of inadequately treated pain in this population. METHODS We will perform a systematic review of pharmacological and non-pharmacological interventions for the management of pain and sedation in newborn infants undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy. We will include randomized, quasi-randomized controlled trials and observational studies. The use of pharmacological or non-pharmacological interventions will be compared to other pharmacological and or non-pharmacological interventions or no intervention/placebo. The primary outcomes for this review will be analgesia and sedation assessed with validated pain scales, circulatory instability, mortality to discharge, and moderate-to-severe neurodevelopmental disability. We will search the following databases: CINAHL, ClinicalTrials.gov , Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Two independent researchers will screen the records for inclusion, extract data using a data extraction form, and assess the risk of bias in the included trials. DISCUSSION The result of this review will summarize the knowledge regarding the management of pain and sedation in infants treated with therapeutic hypothermia and potentially provide clinicians with guidance on the effective and safe methods. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020205755.
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Affiliation(s)
- Pyrola Bäcke
- University Hospital, Neonatal Intensive Care Unit, Uppsala, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Pediatrics, Lund University, Lund, Sweden.,Cochrane Sweden, Research and Development, Skåne University Hospital, Lund, Sweden
| | - Ylva Thernström Blomqvist
- University Hospital, Neonatal Intensive Care Unit, Uppsala, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. .,Faculty of Medicine and Health, School of Health Sciences, Örebro University, 701 82, Örebro, Sweden.
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6
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Mills KP, Lean RE, Smyser CD, Inder T, Rogers C, McPherson CC. Fentanyl Exposure in Preterm Infants: Five-Year Neurodevelopmental and Socioemotional Assessment. FRONTIERS IN PAIN RESEARCH 2022; 3:836705. [PMID: 36061415 PMCID: PMC9429367 DOI: 10.3389/fpain.2022.836705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate the association between cumulative fentanyl dose during neonatal intensive care and 5-year neurodevelopmental and socioemotional outcomes in very preterm infants. Materials and Methods Patient demographics and clinical factors during the perinatal and neonatal course were collected in 84 patients born between 23- and 30-weeks gestational age (GA). Cumulative fentanyl dose during neonatal intensive care was calculated. Developmental testing at age 5 years included the Wechsler Preschool and Primary Scale of Intelligence Full-Scale Intelligence Quotient, Third Edition, Clinical Evaluation of Language Fundamentals-Preschool, Second Edition, Movement Assessment Battery for Children, Second Edition (MABC-2), and Shape School Assessment. Socioemotional outcomes were assessed via caregiver's responses on the Child Behavior Checklist/1.5-5 (CBCL/1.5-5.5) and Social Responsiveness Scale, Second Edition (SRS-2). Covariates were identified on bivariate analysis (p < 0.1). Linear regression models related outcome measures to the log of cumulative fentanyl dose adjusted for covariates. Results Higher cumulative fentanyl dose was associated with lower composite motor scores on bivariate analysis (p < 0.01). Cumulative fentanyl dose did not correlate with composite intelligence quotient, language, or executive function. The Clinical Risk Index for Babies score, log of mechanical ventilation, inotrope, and anesthesia duration, and log of cumulative midazolam and hydrocortisone dose were also associated with MABC-2 scores (p < 0.1). Cumulative fentanyl dose was not associated with composite MABC-2 scores on multiple linear regression. Higher cumulative fentanyl dose was associated with decreased socioemotional problems based on caregiver's response on CBCL/1.5-5.5 t-scores driven by fewer symptoms of depression. The McMaster Family Assessment Device general functioning scale score, maternal age, GA, log of total parenteral nutrition days, patent ductus arteriosus requiring treatment, and log of inotrope hours were also associated with CBCL/1.5-5.5 t-scores (p < 0.1). Cumulative fentanyl dose (p = 0.039) and family dysfunction score (p = 0.002) remained significant after controlling for covariates on multiple linear regression. Conclusion Cumulative fentanyl dose during neonatal intensive care did not correlate with 5-year motor, cognitive, or language outcomes after controlling for other variables. Fentanyl dose was associated with caregiver reported total socioemotional problems on the CBCL/1.5-5.5 on multivariate modeling. Additional long-term studies are needed to fully elucidate the safety of fentanyl in very preterm neonates.
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Affiliation(s)
- Kimberly P. Mills
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, MO, United States
| | - Rachel E. Lean
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| | - Christopher D. Smyser
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, United States
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, United States
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, United States
| | - Terrie Inder
- Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Cynthia Rogers
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, United States
| | - Christopher C. McPherson
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, MO, United States
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, United States
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7
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Abstract
Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.
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Affiliation(s)
- Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, F605B, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver BC V5Z 4H4, Canada
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8
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Campbell-Yeo M, Eriksson M, Benoit B. Assessment and Management of Pain in Preterm Infants: A Practice Update. CHILDREN (BASEL, SWITZERLAND) 2022; 9:244. [PMID: 35204964 PMCID: PMC8869922 DOI: 10.3390/children9020244] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 12/11/2022]
Abstract
Infants born preterm are at a high risk for repeated pain exposure in early life. Despite valid tools to assess pain in non-verbal infants and effective interventions to reduce pain associated with medical procedures required as part of their care, many infants receive little to no pain-relieving interventions. Moreover, parents remain significantly underutilized in provision of pain-relieving interventions, despite the known benefit of their involvement. This narrative review provides an overview of the consequences of early exposure to untreated pain in preterm infants, recommendations for a standardized approach to pain assessment in preterm infants, effectiveness of non-pharmacologic and pharmacologic pain-relieving interventions, and suggestions for greater active engagement of parents in the pain care for their preterm infant.
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Affiliation(s)
- Marsha Campbell-Yeo
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Department of Pediatrics, Psychology and Neuroscience, Dalhousie University, Halifax, NS B3H 4R2, Canada
- IWK Health, Halifax, NS B3K 6R8, Canada
| | - Mats Eriksson
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden;
| | - Britney Benoit
- Rankin School of Nursing, St. Francis Xavier University, Antigonish, NS B2G 2N5, Canada;
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9
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Williams ML, Kannankeril PJ, Breeyear JH, Edwards TL, Van Driest SL, Choi L. Effect of CYP3A5 and CYP3A4 Genetic Variants on Fentanyl Pharmacokinetics in a Pediatric Population. Clin Pharmacol Ther 2021; 111:896-908. [PMID: 34877660 DOI: 10.1002/cpt.2506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/03/2021] [Indexed: 12/30/2022]
Abstract
Fentanyl is an anesthetic/analgesic commonly used in surgical and recovery settings. CYP3A4 and CYP3A5 encode enzymes, which metabolize fentanyl; genetic variants in these genes impact fentanyl pharmacokinetics in adults. Pharmacokinetic (PK) studies are difficult to replicate in children due to the burden of additional blood taken solely for research purposes. The aim of this study is to test the effect of CYP3A5 and CYP3A4 genetic variants on fentanyl PKs in children using opportunistically collected samples. Fentanyl concentrations were measured from remnant blood specimens and dosing data were extracted from electronic health records. Variant data defining CYP3A4*1G and CYP3A5*3 and *6 alleles were available from prior genotyping; alleles with no variant were defined as *1. The study cohort included 434 individuals (median age 9 months, 52% male subjects) and 1,937 fentanyl concentrations were available. A two-compartment model was selected as the base model, and the final covariate model included age, weight, and surgical severity score. Clearance was significantly associated with either CYP3A5*3 or CYP3A5*6 alleles, but not the CYP3A4*1G allele. A genotype of CYP3A5*1/*3 or CYP3A5*1/*6 (i.e., intermediate metabolizer status) was associated with a 0.84-fold (95% confidence interval (CI): 0.71-1.00) reduction in clearance vs. CYP3A5*1/*1 (i.e., normal metabolizer status). CYP3A5*3/*3, CYP3A5*3/*6, or CYP3A5*6/*6 (i.e., poor metabolizer status) was associated with a 0.76-fold (95% CI: 0.58-0.99) reduction in clearance. In the final model, expected clearance was 8.9 and 6.8 L/hour for a normal and poor metabolizer, respectively, with median population covariates (9 months old, 7.7 kg, low surgical severity).
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Affiliation(s)
- Michael L Williams
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Prince J Kannankeril
- Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joseph H Breeyear
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd L Edwards
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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10
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Kurul S, Taal HR, Flint RB, Mazela J, Reiss IKM, Allegaert K, Simons SHP. Protocol: Pentoxifylline optimal dose finding trial in preterm neonates with suspected late onset sepsis (PTX-trial). BMC Pediatr 2021; 21:517. [PMID: 34794420 PMCID: PMC8603542 DOI: 10.1186/s12887-021-02975-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late onset sepsis is a leading cause of death and morbidity in preterm infants. Despite optimal antibiotic treatment, sepsis related mortality and morbidity is still high. Pentoxifylline (PTX) is a methylxanthine with promising immunomodulatory properties, which can be used as an additional therapy next to antibiotics in preterm infants. PTX is increasingly used off-label in neonatal intensive care units, however up till now no dose finding study has been done for PTX in this specific population. The aim of this study (PTX-trial) is to determine the optimal dose of PTX in preterm infants (gestational age < 30 weeks) with (suspected) late onset sepsis. Dose finding in this particular population is unique, since for most drugs used in neonates the optimal dosage has not been investigated in phase II dose-seeking studies. METHODS The PTX-trial is a prospective open label sequential dose-optimization study with an adapted continual reassessment method. An up-and-down dose-response design will be used, with dose step-up and step-down titration after every 3 patients. The PTX starting dosage will be 30 mg/kg/day in 6 hours as described in most previous neonatal studies. Efficacy is defined by means of biochemical and clinical parameters. Toxicity in these vulnerable patients is unwarranted. The optimal dose is defined as the ED75 (i.e., clinically and chemically effective dose for 75% of patients) in preterm neonates with late onset sepsis. We plan to include 30 neonates to determine the optimal dose using this study design. Subsequently, the optimal dose will be validated in 10 additional preterm neonates. In parallel, pharmacokinetics of PTX and its metabolites will be described as well as longitudinal evaluation of metabolomics and proteomics. DISCUSSION The study has been approved by the Regional Medical Ethics Board of Erasmus Medical Center University Rotterdam (MEC 2019-0477) and registered at Clinicaltrials.gov (NCT04152980). Results of the main trial and each of the secondary endpoints will be submitted for publications in peer-reviewed journals. TRIAL REGISTRATION Clinicaltrials.gov, NCT04152980 , Registered November 6th, 2019.
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Affiliation(s)
- Serife Kurul
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
| | - H Rob Taal
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
| | - Robert B Flint
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan Mazela
- Department of Neonatology, Poznan University of Medical Sciences, Poznań, Poland
| | - Irwin K M Reiss
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
| | - Karel Allegaert
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Development and Regeneration and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Sinno H P Simons
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands.
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11
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Pre- and Postnatal Maturation are Important for Fentanyl Exposure in Preterm and Term Newborns: A Pooled Population Pharmacokinetic Study. Clin Pharmacokinet 2021; 61:401-412. [PMID: 34773609 PMCID: PMC8891207 DOI: 10.1007/s40262-021-01076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Fentanyl is an opioid commonly used to prevent and treat severe pain in neonates; however, its use is off label and mostly based on bodyweight. Given the limited pharmacokinetic information across the entire neonatal age range, we characterized the pharmacokinetics of fentanyl across preterm and term neonates to individualize dosing. METHODS We pooled data from two previous studies on 164 newborns with a median gestational age of 29.0 weeks (range 23.9-42.3), birthweight of 1055 g (range 390-4245), and postnatal age (PNA) of 1 day (range 0-68). In total, 673 plasma samples upon bolus dosing (69 patients; median dose 2.1 μg/kg, median 2 boluses per patient) or continuous infusions (95 patients; median dose 1.1 μg/kg/h for 30 h) with and without boluses were used for population pharmacokinetic modeling in NONMEM® 7.4. RESULTS Clearance in neonates with birthweight of 2000 and 3000 g was 2.8- and 5.0-fold the clearance in a neonate with birthweight of 1000 g, respectively. Fentanyl clearance at PNA of 7, 14, and 21 days was 2.7-fold, 3.8-fold, and 4.6-fold the clearance at 1 day, respectively. Bodyweight-based dosing resulted in large differences in fentanyl concentrations. Depending on PNA and birthweight, fentanyl concentrations increased slowly after the start of therapy for both intermittent boluses and continuous infusion and reached a maximum concentration at 12-48 h. CONCLUSIONS As both prenatal and postnatal maturation are important for fentanyl exposure, we propose a birthweight- and PNA-based dosage regimen. To provide rapid analgesia in the first 24 h of treatment, additional loading doses need to be considered.
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12
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Abstract
Almost 50% of prescription drugs lack age-appropriate dosing guidelines and therefore are used "off-label." Only ~10% drugs prescribed to neonates and infants have been studied for safety or efficacy. Immaturity of drug metabolism in children is often associated with drug toxicity. This chapter summarizes data on the ontogeny of major human metabolizing enzymes involved in oxidation, reduction, hydrolysis, and conjugation of drugs. The ontogeny data of individual drug-metabolizing enzymes are important for accurate prediction of drug pharmacokinetics and toxicity in children. This information is critical for designing clinical studies to appropriately test pharmacological hypotheses and develop safer pediatric drugs, and to replace the long-standing practice of body weight- or surface area-normalized drug dosing. The application of ontogeny data in physiologically based pharmacokinetic model and regulatory submission are discussed.
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13
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Völler S, Flint RB, Simons SHP, Knibbe CAJ. Comment on: "Preterm Physiologically Based Pharmacokinetic Model, Part I and Part II". Clin Pharmacokinet 2021; 60:677-679. [PMID: 33713305 PMCID: PMC8113170 DOI: 10.1007/s40262-021-00993-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Swantje Völler
- Leiden Academic Centre for Drug Research, Pharmacy, Leiden University, Leiden, The Netherlands.
| | - Robert B Flint
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Catherijne A J Knibbe
- Leiden Academic Centre for Drug Research, Systems Biomedicine and Pharmacology, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
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14
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Naji-Talakar S, Sharma S, Martin LA, Barnhart D, Prasad B. Potential implications of DMET ontogeny on the disposition of commonly prescribed drugs in neonatal and pediatric intensive care units. Expert Opin Drug Metab Toxicol 2021; 17:273-289. [PMID: 33256492 PMCID: PMC8346204 DOI: 10.1080/17425255.2021.1858051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Introduction: Pediatric patients, especially neonates and infants, are more susceptible to adverse drug events as compared to adults. In particular, immature small molecule drug metabolism and excretion can result in higher incidences of pediatric toxicity than adults if the pediatric dose is not adjusted.Area covered: We reviewed the top 29 small molecule drugs prescribed in neonatal and pediatric intensive care units and compiled the mechanisms of their metabolism and excretion. The ontogeny of Phase I and II drug metabolizing enzymes and transporters (DMETs), particularly relevant to these drugs, are summarized. The potential effects of DMET ontogeny on the metabolism and excretion of the top pediatric drugs were predicted. The current regulatory requirements and recommendations regarding safe and effective use of drugs in children are discussed. A few representative examples of the use of ontogeny-informed physiologically based pharmacokinetic (PBPK) models are highlighted.Expert opinion: Empirical prediction of pediatric drug dosing based on body weight or body-surface area from the adult parameters can be inaccurate because DMETs are not mature in children and the age-dependent maturation of these proteins is different. Ontogeny-informed-PBPK modeling provides a better alternative to predict the pharmacokinetics of drugs in children.
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Affiliation(s)
- Siavosh Naji-Talakar
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Sheena Sharma
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Leslie A. Martin
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Derek Barnhart
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Bhagwat Prasad
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
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15
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Practical approaches to sedation and analgesia in the newborn. J Perinatol 2021; 41:383-395. [PMID: 33250515 PMCID: PMC7700106 DOI: 10.1038/s41372-020-00878-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/06/2020] [Accepted: 11/12/2020] [Indexed: 11/08/2022]
Abstract
The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.
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16
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Sindhur M, Balasubramanian H, Srinivasan L, Kabra NS, Agashe P, Doshi A. Intranasal fentanyl for pain management during screening for retinopathy of prematurity in preterm infants: a randomized controlled trial. J Perinatol 2020; 40:881-887. [PMID: 32054982 DOI: 10.1038/s41372-020-0608-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/27/2020] [Accepted: 02/04/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To study the efficacy of intranasal fentanyl as an adjunct for pain management during screening for retinopathy of prematurity (ROP) in preterm infants. STUDY DESIGN In this single center, double blinded, randomized controlled trial, preterm neonates between 30 and 34 weeks postmenstrual age received either intranasal fentanyl (2 mcg/kg) or intranasal normal saline through a mucosal atomization device 5 min prior to the first ROP-screening examination. Both the groups received standard pain relief strategies (oral sucrose, 0.5% proparacaine eye drops and physical containment). The primary outcome was premature infant pain profile-revised (PIPP-R) score during the screening. RESULTS A total of 111 infants were enrolled. PIPP-R score during the retinal examination was significantly lower in the fentanyl group (8.3 versus 11.5, mean difference: 3.2 (2.46-4.06), P < 0.001). There was no significant difference in the incidence of adverse effects. CONCLUSION Intranasal fentanyl significantly reduced the pain associated with retinal examination without increasing the risk of respiratory depression. Large RCTs are required to verify the efficacy and safety of intranasal fentanyl for acute procedural pain in neonates. CLINICAL TRIAL REGISTRATION CTRI/2017/12/011016.
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Affiliation(s)
| | | | - Lakshmi Srinivasan
- The Children's Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA, USA
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17
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Engbers AGJ, Flint RB, Völler S, de Klerk JCA, Reiss IKM, Andriessen P, Liem KD, Degraeuwe PLJ, Croubels S, Millecam J, Allegaert K, Simons SHP, Knibbe CAJ. Enantiomer specific pharmacokinetics of ibuprofen in preterm neonates with patent ductus arteriosus. Br J Clin Pharmacol 2020; 86:2028-2039. [PMID: 32250464 PMCID: PMC7495289 DOI: 10.1111/bcp.14298] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 03/11/2020] [Accepted: 03/21/2020] [Indexed: 02/06/2023] Open
Abstract
Aims Racemic ibuprofen is widely used for the treatment of preterm neonates with patent ductus arteriosus. Currently used bodyweight‐based dosing guidelines are based on total ibuprofen, while only the S‐enantiomer of ibuprofen is pharmacologically active. We aimed to optimize ibuprofen dosing for preterm neonates of different ages based on an enantiomer‐specific population pharmacokinetic model. Methods We prospectively collected 210 plasma samples of 67 preterm neonates treated with ibuprofen for patent ductus arteriosus (median gestational age [GA] 26 [range 24–30] weeks, median body weight 0.83 [0.45–1.59] kg, median postnatal age [PNA] 3 [1–12] days), and developed a population pharmacokinetic model for S‐ and R‐ibuprofen. Results We found that S‐ibuprofen clearance (CLS, 3.98 mL/h [relative standard error {RSE} 8%]) increases with PNA and GA, with exponents of 2.25 (RSE 6%) and 5.81 (RSE 15%), respectively. Additionally, a 3.11‐fold higher CLS was estimated for preterm neonates born small for GA (RSE 34%). Clearance of R‐ibuprofen was found to be high compared to CLS (18 mL/h [RSE 24%]), resulting in a low contribution of R‐ibuprofen to total ibuprofen exposure. Current body weight was identified as covariate on both volume of distribution of S‐ibuprofen and R‐ibuprofen. Conclusion S‐ibuprofen clearance shows important maturation, especially with PNA, resulting in an up to 3‐fold increase in CLS during a 3‐day treatment regimen. This rapid increase in clearance needs to be incorporated in dosing guidelines by adjusting the dose for every day after birth to achieve equal ibuprofen exposure.
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Affiliation(s)
- Aline G J Engbers
- Division of Systems Biomedicine & Pharmacology, LACDR, Leiden University, Leiden, the Netherlands.,Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Robert B Flint
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacy, Radboud University Medical Centre, Nijmegen, the Netherlands.,Department of Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Swantje Völler
- Division of Systems Biomedicine & Pharmacology, LACDR, Leiden University, Leiden, the Netherlands.,Division of BioTherapeutics, LACDR, Leiden University, Leiden, the Netherlands
| | - Johan C A de Klerk
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Kian D Liem
- Department of Neonatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Pieter L J Degraeuwe
- Department of Paediatrics, Division of Neonatology, Maastricht University Medical Centre, the Netherlands
| | - Siska Croubels
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Belgium
| | - Joske Millecam
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Belgium
| | - Karel Allegaert
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Development and Regeneration, KU Leuven, Belgium
| | - Sinno H P Simons
- Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine & Pharmacology, LACDR, Leiden University, Leiden, the Netherlands.,Department of Paediatrics, Division of Neonatology, Erasmus UMC - Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
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18
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McPherson C, Miller SP, El-Dib M, Massaro AN, Inder TE. The influence of pain, agitation, and their management on the immature brain. Pediatr Res 2020; 88:168-175. [PMID: 31896130 PMCID: PMC7223850 DOI: 10.1038/s41390-019-0744-6] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/11/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
Preterm infants are exposed to frequent painful procedures and agitating stimuli over the many weeks of their hospitalization in the neonatal intensive care unit (NICU). The adverse neurobiological impact of pain and stress in the preterm infant has been well documented, including neuroimaging and neurobehavioral outcomes. Although many tools have been validated to assess acute pain, few methods are available to assess chronic pain or agitation (a clinical manifestation of neonatal stress). Both nonpharmacologic and pharmacologic approaches are used to reduce the negative impact of pain and agitation in the preterm infant, with concerns emerging over the adverse effects of analgesia and sedatives. Considering benefits and risks of available treatments, units must develop a stepwise algorithm to prevent, assess, and treat pain. Nonpharmacologic interventions should be consistently utilized prior to mild to moderately painful procedures. Sucrose may be utilized judiciously as an adjunctive therapy for minor painful procedures. Rapidly acting opioids (fentanyl or remifentanil) form the backbone of analgesia for moderately painful procedures. Chronic sedation during invasive mechanical ventilation represents an ongoing challenge; appropriate containment and an optimal environment should be standard; when indicated, low-dose morphine infusion may be utilized cautiously and dexmedetomidine infusion may be considered as an emerging adjunct.
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Affiliation(s)
- Christopher McPherson
- 0000 0000 9953 7617grid.416775.6Department of Pharmacy, St. Louis Children’s Hospital, St. Louis, MO USA ,0000 0001 2355 7002grid.4367.6Department of Pediatrics, Washington University School of Medicine, St. Louis, MO USA
| | - Steven P. Miller
- 0000 0004 0473 9646grid.42327.30Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON Canada
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - An N. Massaro
- 0000 0004 1936 9510grid.253615.6Department of Pediatrics—Neonatology Division, The George Washington University School of Medicine and Children’s National Health System, Washington, DC USA
| | - Terrie E. Inder
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
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19
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Allegaert K, Smits A, van den Anker JN. Phenobarbital Increases Midazolam Clearance in Neonates Treated with Hypothermia: Do We Really Need to Know? Neonatology 2019; 116:188-190. [PMID: 31185480 DOI: 10.1159/000499742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/19/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Karel Allegaert
- Division of Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands, .,Neonatal Intensive Care Unit, Department of Development and Regeneration, KU Leuven, Leuven, Belgium,
| | - Anne Smits
- Neonatal Intensive Care Unit, Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - John N van den Anker
- Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands.,Division of Clinical Pharmacology, Department of Pediatrics, Children's National Health System, Washington, District of Columbia, USA.,Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
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