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Cardin AD. Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome: An Ecological View of Non-Pharmacologic Interventions for Feeding Success. Crit Care Nurs Clin North Am 2024; 36:235-249. [PMID: 38705691 DOI: 10.1016/j.cnc.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
The number of infants diagnosed with neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS) has increased. The expression of NAS/NOWS symptoms differs and typically begins within the first few days of life, considered a critical period for feeding skill establishment, nourishment, and attachment. Non-pharmacologic interventions may be deployed to reduce or eliminate the need for replacement opioids while targeting outcomes like feeding dysfunction. Critical care providers can benefit from a structured examination of disordered feeding experiences to inform their selection of non-pharmacologic interventions. This structure can be provided using the Ecology of Human Performance model.
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Affiliation(s)
- Ashlea D Cardin
- Missouri State University, 901 S. National Avenue, OCHS 203H, Springfield, MO 65897, USA.
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Curtis S, Kilpatrick R, Billimoria ZC, Zimmerman K, Tolia V, Clark R, Greenberg RG, Puia-Dumitrescu M. Use of Dexmedetomidine and Opioids in Hospitalized Preterm Infants. JAMA Netw Open 2023; 6:e2341033. [PMID: 37921767 PMCID: PMC10625033 DOI: 10.1001/jamanetworkopen.2023.41033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/19/2023] [Indexed: 11/04/2023] Open
Abstract
Importance Dexmedetomidine, an α2-adrenergic agonist, is not approved by the Food and Drug Administration for use in premature infants. However, the off-label use of dexmedetomidine in premature infants has increased 50-fold in the past decade. Currently, there are no large studies characterizing dexmedetomidine use in US neonatal intensive care units (NICUs) or comparing the use of dexmedetomidine vs opioids in infants. Objectives To describe dexmedetomidine use patterns in the NICU and examine the association between dexmedetomidine and opioid use in premature infants. Design, Setting, and Participants A multicenter, observational cohort study was conducted from November 11, 2022, to April 4, 2023. Participants were inborn infants born between 22 weeks, 0 days, and 36 weeks, 6 days, of gestation at 1 of 383 Pediatrix Medical Group NICUs across the US between calendar years 2010 and 2020. Main Outcome and Measure Exposure to medications of interest defined as total days of exposure, timing of use, and changes over time. Results A total of 395 122 infants were included in the analysis. Median gestational age was 34 (IQR, 32-35) weeks, and median birth weight was 2040 (IQR, 1606-2440) g. There were 384 infants (0.1% of total; 58.9% male) who received dexmedetomidine. Infants who received dexmedetomidine were born more immature, had lower birth weight, longer length of hospitalization, more opioid exposure, and more days of mechanical ventilation. Dexmedetomidine use increased from 0.003% in 2010 to 0.185% in 2020 (P < .001 for trend), while overall opioid exposure decreased from 8.5% in 2010 to 7.2% in 2020 (P < .001 for trend). The median postmenstrual age at first dexmedetomidine exposure was 31 (IQR, 27-36) weeks, and the median postnatal age at first dexmedetomidine exposure was 3 (IQR, 1-35) days. The median duration of dexmedetomidine receipt was 6 (IQR, 2-14) days. Conclusion and Relevance The findings of this multicenter cohort study of premature infants suggest that dexmedetomidine use increased significantly between 2010 and 2020, while overall opioid exposure decreased. Future studies are required to further examine the short- and long-term effects of dexmedetomidine in premature and critically ill infants.
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Affiliation(s)
- Samantha Curtis
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Ryan Kilpatrick
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Kanecia Zimmerman
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Veeral Tolia
- Pediatrix Medical Group, Baylor Scott and White Healthcare, Dallas, Texas
| | - Reese Clark
- MEDNAX Center for Research, Education, Quality and Safety, San Antonio, Texas
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
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Wei Z, Gilbert Y, Thananjeyan A, Cope J, Morton RL, Li A, Pham CT, Ward M, Oei JL. A Systematic Review of Clinical Practice Guidelines for Neonatal Abstinence Syndrome. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1685. [PMID: 37892348 PMCID: PMC10605060 DOI: 10.3390/children10101685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The prevalence of neonatal abstinence syndrome is increasing, but the number and quality of clinical practice guidelines available are unknown. This systematic review aimed to identify, appraise and evaluate clinical practice guidelines for neonatal abstinence syndrome. METHODS A systematic search of databases and the grey literature was conducted between 1 June and 1 July 2022. Full-text guidelines published by national or state-wide institutions were included. The recommendations from each guideline were extracted. The AGREE-II instrument was used to assess guideline quality. Sufficient-quality scores were defined as >60 and good-quality scores were >80 for each domain of AGREE-II. RESULTS A total of 1703 records were identified, and 22 guidelines from the United States, Australia, Canada and the United Kingdom, published between 2012 to 2021, were included. The quality scores were low, with median scores of 37/100 for stakeholder involvement, 33/100 for methodology, 34/100 for applicability and 0 for editorial independence. Scope and purpose scored 72/100, and presentation scored 85/100. Sixteen (73%) guidelines did not meet the cut-offs for clinical use. CONCLUSION Many guidelines were of insufficient quality to guide clinical practice for neonatal abstinence syndrome. This emphasises the need for high-quality studies to inform clinical practice guidelines, improve care and reduce the risk of poor outcomes in these high-risk infants.
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Affiliation(s)
- Zoe Wei
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - Yasmin Gilbert
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
- Prince of Wales Hospital, Barker Street, Randwick, Sydney, NSW 2031, Australia
| | - Arabhi Thananjeyan
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - James Cope
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - Rachael L. Morton
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, 92–94 Parramatta Road, Camperdown, Sydney, NSW 2006, Australia
| | - Annie Li
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - Cecile T. Pham
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - Meredith Ward
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
- Department of Newborn Care, The Royal Hospital for Women, Barker Street, Randwick, Sydney, NSW 2031, Australia
| | - Ju Lee Oei
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
- Department of Newborn Care, The Royal Hospital for Women, Barker Street, Randwick, Sydney, NSW 2031, Australia
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Haggerty DL, Grecco GG, Huang JY, Doud EH, Mosley AL, Lu HC, Atwood BK. Prenatal methadone exposure selectively alters protein expression in primary motor cortex: Implications for synaptic function. Front Pharmacol 2023; 14:1124108. [PMID: 36817148 PMCID: PMC9928955 DOI: 10.3389/fphar.2023.1124108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/16/2023] [Indexed: 02/04/2023] Open
Abstract
As problematic opioid use has reached epidemic levels over the past 2 decades, the annual prevalence of opioid use disorder (OUD) in pregnant women has also increased 333%. Yet, how opioids affect the developing brain of offspring from mothers experiencing OUD remains understudied and not fully understood. Animal models of prenatal opioid exposure have discovered many deficits in the offspring of prenatal opioid exposed mothers, such as delays in the development of sensorimotor function and long-term locomotive hyperactivity. In attempt to further understand these deficits and link them with protein changes driven by prenatal opioid exposure, we used a mouse model of prenatal methadone exposure (PME) and preformed an unbiased multi-omic analysis across many sensoriomotor brain regions known to interact with opioid exposure. The effects of PME exposure on the primary motor cortex (M1), primary somatosensory cortex (S1), the dorsomedial striatum (DMS), and dorsolateral striatum (DLS) were assessed using quantitative proteomics and phosphoproteomics. PME drove many changes in protein and phosphopeptide abundance across all brain regions sampled. Gene and gene ontology enrichments were used to assess how protein and phosphopeptide changes in each brain region were altered. Our findings showed that M1 was uniquely affected by PME in comparison to other brain regions. PME uniquely drove changes in M1 glutamatergic synapses and synaptic function. Immunohistochemical analysis also identified anatomical differences in M1 for upregulating the density of glutamatergic and downregulating the density of GABAergic synapses due to PME. Lastly, comparisons between M1 and non-M1 multi-omics revealed conserved brain wide changes in phosphopeptides associated with synaptic activity and assembly, but only specific protein changes in synapse activity and assembly were represented in M1. Together, our studies show that lasting changes in synaptic function driven by PME are largely represented by protein and anatomical changes in M1, which may serve as a starting point for future experimental and translational interventions that aim to reverse the adverse effects of PME on offspring.
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Affiliation(s)
- David L. Haggerty
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Gregory G. Grecco
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States
- Indiana University School of Medicine, Medical Scientist Training Program, Indianapolis, IN, United States
| | - Jui-Yen Huang
- The Linda and Jack Gill Center for Biomolecular Sciences, Indiana University, Bloomington, IN, United States
- Program in Neuroscience and Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, United States
| | - Emma H. Doud
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Amber L. Mosley
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Hui-Chen Lu
- The Linda and Jack Gill Center for Biomolecular Sciences, Indiana University, Bloomington, IN, United States
- Program in Neuroscience and Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, United States
| | - Brady K. Atwood
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, United States
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Liu Y, Liu H. Utilization of Nursing Defect Management Evaluation and Deep Learning in Nursing Process Reengineering Optimization. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:8019385. [PMID: 34819992 PMCID: PMC8608515 DOI: 10.1155/2021/8019385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/23/2021] [Accepted: 10/15/2021] [Indexed: 11/21/2022]
Abstract
It was to explore the application of nursing defect management evaluation and deep learning in nursing process reengineering optimization. This study first selects the root cause analysis method to analyse the nursing defect management, then realizes the classification of data features according to the convolution neural network (CNN) in deep learning (DL) and uses the constructed training set and verification set to obtain the required plates and feature extraction. Based on statistical analysis and data mining, this study makes statistical analysis of nursing data from a macroperspective, improves Apriori algorithm through simulation, and analyses nursing data mining from a microperspective. The constructed deep learning model is used, CNN network training is conducted on the selected SVHN dataset, the required data types are classified, the data are analysed by using the improved Apriori algorithm, and nurses' knowledge of nursing process rules is investigated and analysed. The cognition of nursing staff on process optimization and their participation in training were analyzed, the defects in the nursing process were summarized, and the nursing process reengineering was analyzed. The results show that compared with Apriori algorithm, the running time difference of the improved Apriori algorithm is relatively small. With the increase of data recording times, the line trend of the improved algorithm gradually eases, the advantages gradually appear, and the efficiency of data processing is more obvious. The results showed that after the optimization of nursing process, the effect of long-term specialized nursing was significantly higher than that of long-term nursing. Health education was improved by 7.57%, clinical nursing was improved by 6.55%, ward management was improved by 9.85%, and service humanization was improved by 8.97%. In summary, the reoptimization of nursing process is conducive to reduce the defects in nursing. In the data analysis and rule generation based on deep learning network, the reoptimization of nursing process can provide reference for decision-making departments to improve long-term nursing, improve the quality and work efficiency of clinical nurses, and is worthy of clinical promotion.
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Affiliation(s)
- Yue Liu
- Rainbowfish Rehabilitation & Nursing School, Hangzhou Vocational & Technical College, Hangzhou, Zhejiang, China
| | - Huaping Liu
- School of Nursing, Peking Union Medical College, Beijing, China
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Fragou D, Chao MR, Hu CW, Nikolaou K, Kovatsi L. Global DNA methylation levels in white blood cells of patients with chronic heroin use disorder. A prospective study. Toxicol Rep 2021; 8:337-342. [PMID: 33643851 PMCID: PMC7892979 DOI: 10.1016/j.toxrep.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 12/19/2022] Open
Abstract
Opioid abstinence for 21 days does not affect global DNA methylation levels in white blood cells. All participants in the study completed a 21-day “dry” detoxification program. Findings do not rule out the possibility of site-specific methylation changes.
Background Increasing scientific evidence shows the significant role of epigenetic mechanisms in drug use disorder, abstinence and relapse. Studies on human subjects are limited compared to those on animals, for various reasons such as poly-substance abuse, high drop-out rate and technical difficulties. Objectives Our goal was to evaluate whether a monitored abstinence period of 21 days could induce changes in global DNA methylation in chronic heroin users. Method In the current study, we present data on global DNA methylation on a set of 18 male patients with chronic heroin use disorder, carefully selected based on inclusion and exclusion criteria, who were hospitalized and closely monitored during a 21-day detoxification program, one of the few where no opioid agonist is administered. The participants were sampled twice, once upon enrolment to the program and once upon completion. Results According to our results, no difference in global DNA methylation was detected between samples collected upon enrolment and samples collected upon completion of the program. Conclusion The findings of this study do not rule out the possibility that the 21-day abstinence period was not long enough to observe changes in global DNA methylation, or that abstinence induced site-specific methylation changes (but not global changes), that certainly merit further evaluation.
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Affiliation(s)
- Domniki Fragou
- Laboratory of Forensic Medicine and Toxicology, Department of Medicine, Aristotle University of Thessaloniki, Greece
| | - Mu-Rong Chao
- Department of Occupational Safety and Health, Chung Shan Medical University, Taichung 402, Taiwan
| | - Chiung-Wen Hu
- Department of Public Health, Chung Shan Medical University, Taichung 402, Taiwan
| | - Kakia Nikolaou
- Addiction Department IANOS, General Hospital of Thessaloniki 'G. Papanikolaou'-Psychiatric Hospital of Thessaloniki, Thessaloniki, Greece
| | - Leda Kovatsi
- Laboratory of Forensic Medicine and Toxicology, Department of Medicine, Aristotle University of Thessaloniki, Greece
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McPhail BT, Emoto C, Butler D, Fukuda T, Akinbi H, Vinks AA. Opioid Treatment for Neonatal Opioid Withdrawal Syndrome: Current Challenges and Future Approaches. J Clin Pharmacol 2021; 61:857-870. [PMID: 33382111 DOI: 10.1002/jcph.1811] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/26/2020] [Indexed: 02/06/2023]
Abstract
Chronic intrauterine exposure to psychoactive drugs often results in neonatal opioid withdrawal syndrome (NOWS). When nonpharmacologic measures are insufficient in controlling NOWS, morphine, methadone, and buprenorphine are first-line medications commonly used to treat infants with NOWS because of in utero exposure to opioids. Research suggests that buprenorphine may be the leading drug therapy used to treat NOWS when compared with morphine and methadone. Currently, there are no consensus or standardized treatment guidelines for medications prescribed for NOWS. Opioids used to treat NOWS exhibit large interpatient variability in pharmacokinetics (PK) and pharmacodynamic (PD) response in neonates. Organ systems undergo rapid maturation after birth that may alter drug disposition and exposure for any given dose during development. Data regarding the PK and PD of opioids in neonates are sparse. Pharmacometric methods such as physiologically based pharmacokinetic and population pharmacokinetic modeling can be used to explore factors predictive of some of the variability associated with the PK/PD of opioids in newborns. This review discusses the utility of pharmacometric techniques for enhancing precision dosing in infants requiring opioid treatment for NOWS. Applying these approaches may contribute to optimizing the outcome by reducing cumulative drug exposure, mitigating adverse drug effects, and reducing the burden of NOWS in neonates.
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Affiliation(s)
- Brooks T McPhail
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Butler
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Henry Akinbi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Perinatal Institute, Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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D'Abaco E. Does the addition of clonidine to opioid therapy improve outcomes in infants with Neonatal Abstinence Syndrome? J Paediatr Child Health 2021; 57:155-159. [PMID: 33493373 DOI: 10.1111/jpc.15265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/12/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022]
Abstract
To undertake a literature search and critical appraisal of best available evidence to answer the clinical question: Does the addition of clonidine (I) to standard treatment with an opioid (C) improve outcomes (O) in infants with Neonatal Abstinence Syndrome? A search of both comprehensive (MedLine and Embase) and pre-filtered databases (Dynamed, UpToDate and TRIP), utilising Boolean Operators to combine search terms appropriately. Three relevant studies were identified. One paper describing the outcomes of a randomised controlled trial by Agthe et al. (2009) most accurately answered the clinical question posed. This paper was critically appraised, and evidence applied to the clinical scenario. The use of clonidine as an adjunct to opioid in the management of infants with NAS reduces the total number of treatment days and dose of opioid required to control symptoms. However, there is a higher risk of rebound in symptoms post-cessation of opioid and clinicians need to account for this in their discharge planning. More large scale, multi-centre high-quality research is needed to clarify the role of clonidine in the treatment of NAS: as monotherapy versus adjunct, the optimal dose and longer-term impact on neurodevelopment.
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Affiliation(s)
- Elise D'Abaco
- Paediatric Medicine, Western Health, Joan Kirmer Women's and Children's Hospital, Melbourne, Victoria, Australia.,The University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia
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McPhail BT, Emoto C, Fukuda T, Butler D, Wiles JR, Akinbi H, Vinks AA. Utilizing Pediatric Physiologically Based Pharmacokinetic Models to Examine Factors That Contribute to Methadone Pharmacokinetic Variability in Neonatal Abstinence Syndrome Patients. J Clin Pharmacol 2019; 60:453-465. [PMID: 31820437 DOI: 10.1002/jcph.1538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/09/2019] [Indexed: 12/30/2022]
Abstract
Chronic intrauterine exposure to psychoactive drugs often results in neonatal abstinence syndrome (NAS). NAS is the symptomatic drug withdrawal in newborns that generally occurs after in utero chronic opioid exposure. Methadone is an opioid analgesic commonly prescribed for pharmacologic management of NAS. It exhibits high pharmacokinetic (PK) variability. The current study used physiologically based PK modeling to predict the PK profile of methadone in 20 newborns treated for NAS. The physiologically based PK simulations adequately predicted the PK profile of the clinical data for 45% of the patients. Sensitivity analyses were conducted to explore contributing factors to methadone PK variability. The data suggest that P450 enzymatic activity impacts the clearance of methadone in virtual adults and neonates, while the contribution of cardiac output may be negligible. Understanding maturational and/or pharmacogenetic changes in cytochrome P450 enzymatic activity may further explain the large PK variability of methadone in newborns with NAS and will help individualized treatment.
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Affiliation(s)
- Brooks T McPhail
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Butler
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Henry Akinbi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Perinatal Institute, Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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