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Gosavi A, Amin Z, Carter SWD, Choolani MA, Fee EL, Milad MA, Jobe AH, Kemp MW. Antenatal corticosteroids in Singapore: a clinical and scientific assessment. Singapore Med J 2024; 65:479-487. [PMID: 36254928 DOI: 10.4103/singaporemedj.smj-2022-014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 07/13/2022] [Indexed: 01/28/2023]
Abstract
ABSTRACT Preterm birth (PTB; delivery prior to 37 weeks' gestation) is the leading cause of early childhood death in Singapore today. Approximately 9% of Singaporean babies are born preterm; the PTB rate is likely to increase given the increased use of assisted reproduction technologies, changes in the incidence of gestational diabetes/high body mass index and the ageing maternal population. Antenatal administration of dexamethasone phosphate is a key component of the obstetric management of Singaporean women who are at risk of imminent preterm labour. Dexamethasone improves preterm outcomes by crossing the placenta to functionally mature the fetal lung. The dexamethasone regimen used in Singapore today affords a very high maternofetal drug exposure over a brief period of time. Drawing on clinical and experimental data, we reviewed the pharmacokinetic profile and pharmacodynamic effects of dexamethasone treatment regimen in Singapore, with a view to creating a development pipeline for optimising this critically important antenatal therapy.
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Affiliation(s)
- Arundhati Gosavi
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zubair Amin
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sean William David Carter
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Mahesh Arjandas Choolani
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Erin Lesley Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Mark Amir Milad
- Milad Pharmaceutical Consulting LLC, Plymouth, Michigan, USA
| | - Alan Hall Jobe
- Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew Warren Kemp
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
- School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
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2
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Song L, Song J, Wang Y, Wei Y, Zhao Y, Liu D. Systematic Quantitative Analysis of Fetal Dexamethasone Exposure and Fetal Lung Maturation in Pregnant Animals: Model Informed Dexamethasone Precision Dose Study. ACS Pharmacol Transl Sci 2024; 7:1770-1782. [PMID: 38898943 PMCID: PMC11184600 DOI: 10.1021/acsptsci.3c00391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 06/21/2024]
Abstract
Dexamethasone (DEX) was applied in neonatal respiratory distress syndrome treatment of pregnant women. We established a pharmacokinetics (PK)/pharmacodynamics(PD)/end point model of pregnant animals based on published data and then extrapolated to simulate fetal exposure and lung maturation in pregnant women. We first established the PK/PD/end point model for DEX in pregnant sheep. We considered the competitive effect of cortisol (Cort) and DEX binding with glucocorticoid receptor and then used the indirect response model to describe disaturated-phosphatidylcholine (DSPC) dynamics. Based on that, we established a regression relationship between DSPC and fetal lung volume (V40). We then extrapolated the PD/end point model of pregnant sheep to pregnant monkeys by corrected stages of morphologic lung maturation in two species. Finally, we utilized the interspecies extrapolation strategy to simulate fetal exposure (AUC0-48h) and V40 relationship in pregnant women. The current model could well describe the maternal-fetal PK of DEX in pregnant animals. Simulated DEX AUC0-24h values of the umbilical venous to maternal plasma ratio in pregnant sheep and monkeys were 0.31 and 0.27, respectively. The simulated Cort curve and V40 in pregnant sheep closely matched the observed data within a 2-fold range. For pregnant monkeys, model-simulated V40 were well fitted with external verification data, which showed good interspecies extrapolation performance. Finally, we simulated fetal exposure-response relationship in pregnant women, which indicated that the fetal AUC0-48h of DEX should not be less than 300 and 100 ng/mL·hr at GW28 and GW34 to ensure fetal lung maturity. The current model preliminarily provided support for clinical DEX dose optimization.
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Affiliation(s)
- Ling Song
- Department
of Obstetrics and Gynecology, Peking University
Third Hospital, Beijing 100191, China
- Drug
Clinical Trial Center, Peking University
Third Hospital, Beijing 100191, China
| | - Jie Song
- Drug
Clinical Trial Center, Peking University
Third Hospital, Beijing 100191, China
| | - Ying Wang
- Department
of Obstetrics and Gynecology, Peking University
Third Hospital, Beijing 100191, China
| | - Yuan Wei
- Department
of Obstetrics and Gynecology, Peking University
Third Hospital, Beijing 100191, China
| | - Yangyu Zhao
- Department
of Obstetrics and Gynecology, Peking University
Third Hospital, Beijing 100191, China
| | - Dongyang Liu
- Drug
Clinical Trial Center, Peking University
Third Hospital, Beijing 100191, China
- Institute
of Medical Innovation and Research, Peking
University Third Hospital, Beijing 100191, China
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3
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Adegboyega TA, Adejuyigbe EA, Adesina OA, Adeyemi B, Ahmed S, Akinkunmi F, Aluvaala J, Anyabolu H, Ariff S, Arya S, Awowole I, Ayede AI, Babar N, Bachani S, Bahl R, Baqui AH, Chellani H, Chowdhury SB, Coppola LM, Cousens S, Debata PK, de Costa A, Dhaded SM, Donimath KV, Falade AG, Goudar SS, Gupta S, Gwako GN, Irinyenikan TA, Isah DA, Jabeen N, Javed A, Joseph NT, Khanam R, Kinuthia J, Kuti O, Lavin T, Laving AR, Maranna S, Minckas N, Mittal P, Mohan D, Nausheen S, Nguyen MH, Oladapo OT, Olutekunbi OA, Oluwafemi RO, Osoti A, Pujar YV, Qureshi ZP, Rao SPN, Sarrassat S, Shahed MA, Shahidullah M, Sheikh L, Somannavar MS, Soofi S, Suri J, Vernekar SS, Vogel JP, Wadhwa N, Wari PK, Were F, Wylie BJ. The World Health Organization Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns (ACTION-III) Trial: study protocol for a multi-country, multi-centre, double-blind, three-arm, placebo-controlled, individually randomized trial of antenatal corticosteroids for women at high probability of late preterm birth in hospitals in low- resource countries. Trials 2024; 25:258. [PMID: 38609983 PMCID: PMC11010373 DOI: 10.1186/s13063-024-07941-0] [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: 09/27/2023] [Accepted: 01/17/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Preterm birth complications are the leading cause of newborn and under-5 mortality. Over 85% of all preterm births occur in the late preterm period, i.e. between 34 and < 37 weeks of gestation. Antenatal corticosteroids (ACS) prevent mortality and respiratory morbidity when administered to women at high risk of an early preterm birth, i.e. < 34 weeks' gestation. However, the benefits and risks of ACS in the late preterm period are less clear; both guidelines and practices vary between settings. Emerging evidence suggests that the benefits of ACS may be achievable at lower doses than presently used. This trial aims to determine the efficacy and safety of two ACS regimens compared to placebo, when given to women with a high probability of late preterm birth, in hospitals in low-resource countries. METHODS WHO ACTION III trial is a parallel-group, three-arm, individually randomized, double-blind, placebo-controlled trial of two ACS regimens: dexamethasone phosphate 4 × 6 mg q12h or betamethasone phosphate 4 × 2 mg q 12 h. The trial is being conducted across seven sites in five countries-Bangladesh, India, Kenya, Nigeria, and Pakistan. Eligible women are those with a gestational age between 34 weeks 0 days and 36 weeks 5 days, who have a high probability of preterm birth between 12 h and 7 days (up to 36 weeks 6 days gestation). The primary outcome is a composite of stillbirth or neonatal death within 72 h of birth or use of newborn respiratory support within 72 h of birth or prior to discharge from hospital, whichever is earlier. Secondary outcomes include safety and health utilization measures for both women and newborns. The sample size is 13,500 women. DISCUSSION This trial will evaluate the benefits and possible harms of ACS when used in women likely to have a late preterm birth. It will also evaluate a lower-dose ACS regimen based on literature from pharmacokinetic studies. The results of this trial will provide robust critical evidence on the safe and appropriate use of ACS in the late preterm period internationally. TRIAL REGISTRATION ISRCTN11434567 . Registered on 7 June 2021.
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Chawanpaiboon S, Chukaew R, Pooliam J. A comparison of 2 doses of antenatal dexamethasone for the prevention of respiratory distress syndrome: an open-label, noninferiority, pragmatic randomized trial. Am J Obstet Gynecol 2024; 230:260.e1-260.e19. [PMID: 37442247 DOI: 10.1016/j.ajog.2023.07.006] [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] [Received: 02/26/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Antenatal corticosteroids have been used for the prevention of respiratory complications, intraventricular hemorrhage, necrotizing enterocolitis, and other adverse neonatal outcomes for over 50 years, with limited evidence about their optimal doses. Higher steroid doses or frequencies of antenatal corticosteroids in preterm newborns pose adverse effects such as prolonged adrenal suppression, negative effects on fetal programming and metabolism, and increased risks of neurodevelopmental and neuropsychological impairments. Conversely, lower doses of antenatal corticosteroids may be an effective alternative to induce fetal lung maturation with less risk to the fetus. Late preterm births represent the largest population of all preterm neonates, with a respiratory distress syndrome risk of 8.83%. Therefore, determining the optimal antenatal corticosteroid dosage is of particular importance for this population. OBJECTIVE This study aimed to compare the efficacy of 5-mg and 6-mg dexamethasone in preventing neonatal respiratory distress syndrome in women with preterm births at 320 to 366 weeks of gestation. STUDY DESIGN This was an open-label, randomized, controlled, noninferiority trial. Singleton pregnant women (n=370) at 320 to 366 weeks of gestation with spontaneous preterm labor or preterm premature rupture of membranes were enrolled. They were randomly assigned (1:1) to a 5-mg or 6-mg dexamethasone group. Dexamethasone was administered intramuscularly every 12 hours for 4 doses or until delivery. The primary outcome was the reduction in neonatal respiratory distress syndrome cases, whereas the secondary outcomes were any adverse maternal or neonatal events. RESULTS Between December 2020 and April 2022, 370 eligible women, anticipating deliveries within the gestational range of 32 0/7 to 36 6/7 weeks, willingly participated in the study. They were evenly split, with 185 women assigned to the 5-mg group and 185 to the 6-mg group. The study revealed that the demographic profiles of the participants in the 2 groups were remarkably similar, with no statistically significant disparities (P>.05). It is noteworthy that most of these women gave birth after 34 weeks of gestation. Despite a substantial proportion not completing the full course of steroid treatment, the 5-mg dose exhibited noninferiority compared with the 6-mg dose of dexamethasone, as indicated by a modest proportional difference of 0.5% (95% confidence interval, -2.8 to 43.9). Neonatal respiratory distress syndrome occurred in a relatively low percentage of newborns in both groups, affecting 2.2% in the 5-mg group and 1.6% in the 6-mg group. Notably, the risk difference of 0.6% fell comfortably within the predefined noninferiority threshold of 10%. CONCLUSION Our study suggests that a 5-mg dexamethasone dose is noninferior to a standard 6-mg dose in preventing neonatal respiratory distress syndrome in preterm births.
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Affiliation(s)
- Saifon Chawanpaiboon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Ronnakorn Chukaew
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Julaporn Pooliam
- Clinical Epidemiological Unit, Office for Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Kumagai Y, Kemp MW, Usuda H, Takahashi T, Takahashi Y, Hamada H, Schmidt AF, Hanita T, Watanabe S, Sato S, Ikeda H, Fee EL, Furfaro L, Newnham JP, Jobe AH, Yaegashi N, Saito M. A Reduction in Antenatal Steroid Dose Was Associated with Reduced Cardiac Dysfunction in a Sheep Model of Pregnancy. Reprod Sci 2023; 30:3222-3234. [PMID: 37264260 PMCID: PMC10643432 DOI: 10.1007/s43032-023-01264-2] [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: 02/05/2023] [Accepted: 05/07/2023] [Indexed: 06/03/2023]
Abstract
Despite widespread use, dosing regimens for antenatal corticosteroid (ACS) therapy are poorly unoptimized. ACS therapy exerts a programming effect on fetal development, which may be associated with an increased risk of cardiovascular disease. Having demonstrated that low-dose steroid therapy is an efficacious means of maturing the preterm lung, we hypothesized that a low-dose steroid exposure would exert fewer adverse functional and transcriptional changes on the fetal heart. We tested this hypothesis using low-dose steroid therapy (10 mg delivered to the ewe over 36 h via constant infusion) and compared cardiac effects with those of a higher dose treatment (30 mg delivered to the ewe over 24 h by intramuscular injection; simulating currently employed clinical ACS regimens). Fetal cardiac function was assessed by ultrasound on the day of ACS treatment initiation. Transcriptomic analyses were performed on fetal myocardial tissue. Relative to saline control, fetuses in the higher-dose clinical treatment group had significantly lower ratios between early diastolic ventricular filling and ventricular filling during atrial systole, and showed the differential expression of myocardial hypertrophy-associated transcripts including βMHC, GADD45γ, and PPARγ. The long-term implications of these changes remain unstudied. Irrespective, optimizing ACS dosing regimens to maximize respiratory benefit while minimizing adverse effects on key organ systems, such as the heart, offers a means of improving the acute and long-term outcomes associated with this important obstetric therapy.
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Affiliation(s)
- Yusaku Kumagai
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan.
| | - Matthew W Kemp
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA, Australia
- College of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haruo Usuda
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA, Australia
| | - Tsukasa Takahashi
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA, Australia
| | - Yuki Takahashi
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA, Australia
| | - Hirotaka Hamada
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | | | - Takushi Hanita
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shimpei Watanabe
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shinichi Sato
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hideyuki Ikeda
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Erin L Fee
- Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA, Australia
| | - Lucy Furfaro
- Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA, Australia
| | - John P Newnham
- Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA, Australia
- Cincinnati Children's Hospital Medical Centre, Cincinnati, OH, USA
| | - Nobuo Yaegashi
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Masatoshi Saito
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA, Australia
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6
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Garrud TAC, Teulings NEWD, Niu Y, Skeffington KL, Beck C, Itani N, Conlon FG, Botting KJ, Nicholas LM, Tong W, Derks JB, Ozanne SE, Giussani DA. Molecular mechanisms underlying adverse effects of dexamethasone and betamethasone in the developing cardiovascular system. FASEB J 2023; 37:e22887. [PMID: 37132324 PMCID: PMC10946807 DOI: 10.1096/fj.202200676rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 03/02/2023] [Accepted: 03/09/2023] [Indexed: 05/04/2023]
Abstract
Antenatal glucocorticoids accelerate fetal lung maturation and reduce mortality in preterm babies but can trigger adverse effects on the cardiovascular system. The mechanisms underlying off-target effects of the synthetic glucocorticoids mostly used, Dexamethasone (Dex) and Betamethasone (Beta), are unknown. We investigated effects of Dex and Beta on cardiovascular structure and function, and underlying molecular mechanism using the chicken embryo, an established model system to isolate effects of therapy on the developing heart and vasculature, independent of effects on the mother or placenta. Fertilized eggs were treated with Dex (0.1 mg kg-1 ), Beta (0.1 mg kg-1 ), or water vehicle (Control) on embryonic day 14 (E14, term = 21 days). At E19, biometry, cardiovascular function, stereological, and molecular analyses were determined. Both glucocorticoids promoted growth restriction, with Beta being more severe. Beta compared with Dex induced greater cardiac diastolic dysfunction and also impaired systolic function. While Dex triggered cardiomyocyte hypertrophy, Beta promoted a decrease in cardiomyocyte number. Molecular changes of Dex on the developing heart included oxidative stress, activation of p38, and cleaved caspase 3. In contrast, impaired GR downregulation, activation of p53, p16, and MKK3 coupled with CDK2 transcriptional repression linked the effects of Beta on cardiomyocyte senescence. Beta but not Dex impaired NO-dependent relaxation of peripheral resistance arteries. Beta diminished contractile responses to potassium and phenylephrine, but Dex enhanced peripheral constrictor reactivity to endothelin-1. We conclude that Dex and Beta have direct differential detrimental effects on the developing cardiovascular system.
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Affiliation(s)
- Tessa A. C. Garrud
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Noor E. W. D. Teulings
- Institute of Metabolic Science‐Metabolic Research Laboratories, MRC Metabolic Diseases UnitUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
| | - Youguo Niu
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Katie L. Skeffington
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Christian Beck
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Nozomi Itani
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Fiona G. Conlon
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Kimberley J. Botting
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Lisa M. Nicholas
- Institute of Metabolic Science‐Metabolic Research Laboratories, MRC Metabolic Diseases UnitUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
| | - Wen Tong
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Jan B. Derks
- Department of Perinatal MedicineUniversity Medical CentreUtrechtNetherlands
| | - Susan E. Ozanne
- Institute of Metabolic Science‐Metabolic Research Laboratories, MRC Metabolic Diseases UnitUniversity of Cambridge, Addenbrooke's HospitalCambridgeUK
- BHF Cardiovascular Centre for Research ExcellenceUniversity of CambridgeCambridgeUK
- Strategic Research Initiative in ReproductionUniversity of CambridgeCambridgeUK
- Centre for Trophoblast ResearchUniversity of CambridgeCambridgeUK
| | - Dino A. Giussani
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeCambridgeUK
- BHF Cardiovascular Centre for Research ExcellenceUniversity of CambridgeCambridgeUK
- Strategic Research Initiative in ReproductionUniversity of CambridgeCambridgeUK
- Centre for Trophoblast ResearchUniversity of CambridgeCambridgeUK
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7
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Usuda H, Fee EL, Carter S, Furfaro L, Takahashi T, Takahashi Y, Newnham JP, Milad MA, Saito M, Jobe AH, Kemp MW. Low-dose antenatal betamethasone treatment achieves preterm lung maturation equivalent to that of the World Health Organization dexamethasone regimen but with reduced endocrine disruption in a sheep model of pregnancy. Am J Obstet Gynecol 2022; 227:903.e1-903.e16. [PMID: 35792176 DOI: 10.1016/j.ajog.2022.06.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 06/08/2022] [Accepted: 06/28/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The intramuscular administration of antenatal steroids to women at risk of preterm delivery achieves high maternal and fetal plasma steroid concentrations, which are associated with adverse effects and may reduce treatment efficacy. We have demonstrated that antenatal steroid efficacy is independent of peak maternofetal steroid levels once exposure is maintained above a low threshold. OBJECTIVE This study aimed to test, using a sheep model of pregnancy, whether the low-dose antenatal steroid regimen proposed as part of the Antenatal Corticosteroids for Improving Outcomes in Preterm Newborns trial would achieve preterm lung maturation equivalent to that of the existing World Health Organization dexamethasone treatment regimen, but with reduced risk of adverse outcomes. STUDY DESIGN Following ethical review and approval, date-mated ewes with single fetuses received intramuscular injections of either (1) four 6-mg maternal intramuscular injections of dexamethasone phosphate every 12 hours (n=22), (2) 4 2-mg maternal intramuscular injections of betamethasone phosphate every 12 hours (n=21), or (3) 4 2-mL maternal intramuscular injections of saline every 12 hours (n=16). Of note, 48 hours after first injection, (124±1 day), lambs were delivered, ventilated for 30 minutes, and euthanized for sampling. Arterial blood gas, respiratory, hematological, and biochemical data were analyzed for between-group differences with analysis of variance according to distribution and variance, with P<.05 taken as significant. RESULTS After 30 minutes of ventilation, lambs from both steroid-treated groups had significant and equivalent improvements in lung function relative to saline control (P<.05). There was no significant difference in arterial blood pH, pO2, pCO2, lung compliance, ventilator efficiency index, or lung volume at necropsy with a static pressure of 40 cmH2O. The messenger RNA expression of surfactant protein (Sp)a, Spb, Spc, Spd, aquaporin (Aqp)1, Aqp5, and sodium channel epithelial 1 subunit beta (Scnn1b) was equivalent between both steroid groups. Maternal and fetal plasma neutrophil, glucose, and fetal plasma C-peptide levels were significantly elevated in the dexamethasone group, relative to the betamethasone group. Fetal plasma insulin-like growth factor 1 was significantly reduced in the dexamethasone group compared with the betamethasone group (P<0.05). Fetal adrenocorticotropic hormone (r=0.53), maternal glucose value (r=-0.52), and fetal glucose values (r=-0.42) were correlated with maternal weight in the betamethasone group (P<.05), whereas fetal pCO2 and pO2 were not correlated. There was no significant difference between male and female lamb outcomes in any groups for any of the items evaluated. CONCLUSION This study reported that in preterm lambs, a low-dose treatment regimen of 8 mg betamethasone achieves lung maturation equivalent to that of a 24-mg dexamethasone-based regimen, but with smaller perturbations to the maternofetal hypothalamic-pituitary-adrenal axis. These data suggested that given steroid pharmacokinetic differences between sheep and humans, a betamethasone dose of 2 mg may remain above the minimum dose necessary for robust maturation of the preterm lung. Maternal weight-adjusted betamethasone doses might also be a key to reducing perturbations to the maternofetal hypothalamic-pituitary-adrenal axis.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Erin L Fee
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Sean Carter
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Lucy Furfaro
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yuki Takahashi
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - John P Newnham
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; School of Veterinary and Life Sciences, Murdoch University, Western Australia, Australia
| | - Mark A Milad
- School of Veterinary and Life Sciences, Murdoch University, Western Australia, Australia
| | - Masatoshi Saito
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Alan H Jobe
- Milad Pharmaceutical Consulting LLC, Plymouth, MI
| | - Matthew W Kemp
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan; Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical School, Cincinnati, OH; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Queenstown, Singapore.
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8
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Takahashi T, Takahashi Y, Fee EL, Saito M, Yaegashi N, Usuda H, Bridges JP, Milad MA, Furfaro L, Carter S, Schmidt AF, Newnham JP, Jobe AH, Kemp MW. Continuous but not pulsed low-dose fetal betamethasone exposures extend the durability of antenatal steroid therapy. Am J Physiol Lung Cell Mol Physiol 2022; 322:L784-L793. [PMID: 35380907 DOI: 10.1152/ajplung.00018.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Antenatal steroid (ANS) therapy is standard care for women at imminent risk of preterm labor. Despite extensive and long-standing use, 40-50% of babies exposed antenatally to steroids do not derive benefit; remaining undelivered 7d or more after ANS treatment is associated with a lack of treatment benefit, and increased risk of harms. We used a pregnant sheep model to evaluate the impact of continuous vs. pulsed ANS treatments on fetal lung maturation at an extended, eight-day treatment to delivery interval. Continuous low-dose ANS treatments for more than 72 hours in duration improved fetal lung maturation at eight days after treatment initiation. If fetal ANS exposure was interrupted, the beneficial ANS effect was lost. Truncated treatments, including that simulating the current clinical treatment regimen, did not improve lung function. Variable fetal lung maturation was correlated to the amount of saturated phosphatidylcholine present in the lung fluid. These data demonstrate that: i) the durability of ANS therapy may be enhanced by employing an extended, low-dose treatment regimen with reducing total dose; and ii) interrupting the continuity of fetal exposure by allowing it to fall below a minimal threshold was associated with comparably poor functional maturation of the preterm ovine lung.
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Affiliation(s)
- Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yuki Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Masatoshi Saito
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Nobuo Yaegashi
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - James P Bridges
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Mark A Milad
- Milad Pharmaceutical Consulting LLC, Plymouth, MI, United States
| | - Lucy Furfaro
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Sean Carter
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Augusto F Schmidt
- Department of Neonatology, Pulmonary Biology and Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, United States.,Miller School of Medicine, University of Miami, Miami, FL, United States
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Alan Hall Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia.,Department of Neonatology, Pulmonary Biology and Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, United States
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan.,School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia.,Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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9
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Ivy JR, Carter RN, Zhao JF, Buckley C, Urquijo H, Rog-Zielinska EA, Panting E, Hrabalkova L, Nicholson C, Agnew EJ, Kemp MW, Morton NM, Stock SJ, Wyrwoll C, Ganley IG, Chapman KE. Glucocorticoids regulate mitochondrial fatty acid oxidation in fetal cardiomyocytes. J Physiol 2021; 599:4901-4924. [PMID: 34505639 DOI: 10.1113/jp281860] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/19/2021] [Indexed: 11/08/2022] Open
Abstract
The late gestational rise in glucocorticoids contributes to the structural and functional maturation of the perinatal heart. Here, we hypothesized that glucocorticoid action contributes to the metabolic switch in perinatal cardiomyocytes from carbohydrate to fatty acid oxidation. In primary mouse fetal cardiomyocytes, dexamethasone treatment induced expression of genes involved in fatty acid oxidation and increased mitochondrial oxidation of palmitate, dependent upon a glucocorticoid receptor (GR). Dexamethasone did not, however, induce mitophagy or alter the morphology of the mitochondrial network. In vivo, in neonatal mice, dexamethasone treatment induced cardiac expression of fatty acid oxidation genes. However, dexamethasone treatment of pregnant C57Bl/6 mice at embryonic day (E)13.5 or E16.5 failed to induce fatty acid oxidation genes in fetal hearts assessed 24 h later. Instead, at E17.5, fatty acid oxidation genes were downregulated by dexamethasone, as was GR itself. PGC-1α, required for glucocorticoid-induced maturation of primary mouse fetal cardiomyocytes in vitro, was also downregulated in fetal hearts at E17.5, 24 h after dexamethasone administration. Similarly, following a course of antenatal corticosteroids in a translational sheep model of preterm birth, both GR and PGC-1α were downregulated in heart. These data suggest that endogenous glucocorticoids support the perinatal switch to fatty acid oxidation in cardiomyocytes through changes in gene expression rather than gross changes in mitochondrial volume or mitochondrial turnover. Moreover, our data suggest that treatment with exogenous glucocorticoids may interfere with normal fetal heart maturation, possibly by downregulating GR. This has implications for clinical use of antenatal corticosteroids when preterm birth is considered a possibility. KEY POINTS: Glucocorticoids are steroid hormones that play a vital role in late pregnancy in maturing fetal organs, including the heart. In fetal cardiomyocytes in culture, glucocorticoids promote mitochondrial fatty acid oxidation, suggesting they facilitate the perinatal switch from carbohydrates to fatty acids as the predominant energy substrate. Administration of a synthetic glucocorticoid in late pregnancy in mice downregulates the glucocorticoid receptor and interferes with the normal increase in genes involved in fatty acid metabolism in the heart. In a sheep model of preterm birth, antenatal corticosteroids (synthetic glucocorticoid) downregulates the glucocorticoid receptor and the gene encoding PGC-1α, a master regulator of energy metabolism. These experiments suggest that administration of antenatal corticosteroids in anticipation of preterm delivery may interfere with fetal heart maturation by downregulating the ability to respond to glucocorticoids.
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Affiliation(s)
- Jessica R Ivy
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Roderic N Carter
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Jin-Feng Zhao
- Medical Research Council Protein Phosphorylation and Ubiquitylation Unit, University of Dundee, Dundee, UK
| | - Charlotte Buckley
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Helena Urquijo
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Eva A Rog-Zielinska
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Emma Panting
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK.,School of Human Sciences, The University of Western Australia, Crawley, Australia
| | - Lenka Hrabalkova
- The Centre for Reproductive Health, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Cara Nicholson
- The Centre for Reproductive Health, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Emma J Agnew
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Matthew W Kemp
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore.,Division of Obstetrics and Gynaecology, The University of Western Australia, Crawley, Western Australia, Australia.,Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Nicholas M Morton
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Sarah J Stock
- The Centre for Reproductive Health, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK.,Division of Obstetrics and Gynaecology, The University of Western Australia, Crawley, Western Australia, Australia.,The Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Caitlin Wyrwoll
- School of Human Sciences, The University of Western Australia, Crawley, Australia
| | - Ian G Ganley
- Medical Research Council Protein Phosphorylation and Ubiquitylation Unit, University of Dundee, Dundee, UK
| | - Karen E Chapman
- University/BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK.,School of Human Sciences, The University of Western Australia, Crawley, Australia
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10
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Song D, Jusko WJ. Across‐species meta‐analysis of dexamethasone pharmacokinetics utilizing allometric and scaling modeling approaches. Biopharm Drug Dispos 2021; 42:191-203. [DOI: 10.1002/bdd.2266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/15/2021] [Accepted: 01/27/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Dawei Song
- Department of Pharmaceutical Sciences School of Pharmacy and Pharmaceutical Sciences State University of New York at Buffalo Buffalo New York USA
| | - William J Jusko
- Department of Pharmaceutical Sciences School of Pharmacy and Pharmaceutical Sciences State University of New York at Buffalo Buffalo New York USA
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11
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Jobe AH, Kemp M, Schmidt A, Takahashi T, Newnham J, Milad M. Antenatal corticosteroids: a reappraisal of the drug formulation and dose. Pediatr Res 2021; 89:318-325. [PMID: 33177675 PMCID: PMC7892336 DOI: 10.1038/s41390-020-01249-w] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 12/22/2022]
Abstract
We review the history of antenatal corticosteroid therapy (ACS) and present recent experimental data to demonstrate that this, one of the pillars of perinatal care, has been inadequately evaluated to minimize fetal exposure to these powerful medications. There have been concerns since 1972 that fetal exposures to ACS convey risk. However, this developmental modulator, with its multiple widespread biologic effects, has not been evaluated for drug choice, dose, or duration of treatment, despite over 30 randomized trials. The treatment used in the United States is two intramuscular doses of a mixture of 6 mg betamethasone phosphate (Beta P) and 6 mg betamethasone acetate (Beta Ac). To optimize outcomes with ACS, the goal should be to minimize fetal drug exposure. We have determined that the minimum exposure needed for fetal lung maturation in sheep, monkeys, and humans (based on published cord blood corticosteroid concentrations) is about 1 ng/ml for a 48-h continuous exposure, far lower than the concentration reached by the current dosing. Because the slowly released Beta Ac results in prolonged fetal exposure, a drug containing Beta Ac is not ideal for ACS use. IMPACT: Using sheep and monkey models, we have defined the minimum corticosteroid exposure for a fetal lung maturation. These results should generate new clinical trials of antenatal corticosteroids (ACS) at much lower fetal exposures to ACS, possibly given orally, with fewer risks for the fetus.
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Affiliation(s)
- Alan H. Jobe
- grid.1012.20000 0004 1936 7910Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA Australia ,grid.24827.3b0000 0001 2179 9593Perinatal Institute, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH USA
| | - Matthew Kemp
- grid.1012.20000 0004 1936 7910Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA Australia ,grid.412757.20000 0004 0641 778XCentre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan ,grid.1025.60000 0004 0436 6763School of Veterinary and Life Sciences, Murdoch University, Perth, WA Australia
| | - Augusto Schmidt
- grid.26790.3a0000 0004 1936 8606Division of Neonatology, Department of Pediatrics, University of Miami, Miami, FL USA
| | - Tsukasa Takahashi
- grid.1012.20000 0004 1936 7910Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA Australia ,grid.412757.20000 0004 0641 778XCentre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - John Newnham
- grid.1012.20000 0004 1936 7910Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA Australia
| | - Mark Milad
- Milad Pharmaceutical Consulting, Plymouth, MI USA
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12
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Hofer OJ, McKinlay CJD, Tran T, Crowther CA. Antenatal corticosteroids, maternal body mass index and infant morbidity within the ASTEROID trial. Aust N Z J Obstet Gynaecol 2020; 61:380-385. [PMID: 33372291 DOI: 10.1111/ajo.13291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antenatal corticosteroids (ACSs) administered to women before preterm birth improve neonatal health. Proportionately more women are obese or overweight in current obstetric populations than those who were included in the original trials of ACSs, and it remains uncertain if higher doses are required for such women. AIM Our aim was to assess the association between maternal body mass index (BMI) and infant morbidity after the administration of ACSs. METHODS In the secondary analysis of the ASTEROID trial cohort, women at risk of preterm birth at <34 weeks' gestation were randomised to betamethasone or dexamethasone. Infant outcomes were compared according to whether women were of normal weight (BMI < 25 kg/m2 ), overweight (BMI 25-29.9 kg/m2 ) or obese (BMI ≥ 30 kg/m2 ). RESULTS Of 982 women with a singleton pregnancy and BMI data, 519 (52.9%) were of normal size, 241 (24.5%) were overweight and 222 (22.6%) were obese. Compared with infants born to women of normal weight, there was little or no difference in respiratory distress syndrome in infants born to women who were overweight (odds ratio (OR) = 0.92, 95% confidence interval (CI) 0.57, 1.49) or obese (OR = 1.44, 95% CI 0.90, 2.31). Similarly, there were no significant differences between infants born to women in the three BMI groups for other morbidities, including bronchopulmonary dysplasia, mechanical ventilation, intraventricular haemorrhage, retinopathy of prematurity, patent ductus arteriosus, necrotising enterocolitis, perinatal death or combined serious morbidity. CONCLUSIONS Maternal body size is not associated with infant morbidity after ACS exposure. Dose adjustment for women with higher BMI is not required.
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Affiliation(s)
- Olivia J Hofer
- Liggins Institute and Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - Thach Tran
- Osteoporosis and Bone Biology, Garvan Institute of Medical Research, Sydney, NSW, Australia
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13
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Jobe AH, Milad MA, Peppard T, Jusko WJ. Pharmacokinetics and Pharmacodynamics of Intramuscular and Oral Betamethasone and Dexamethasone in Reproductive Age Women in India. Clin Transl Sci 2020; 13:391-399. [PMID: 31808984 PMCID: PMC7070803 DOI: 10.1111/cts.12724] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/24/2019] [Indexed: 01/23/2023] Open
Abstract
High-dose betamethasone and dexamethasone are standard of care treatments for women at risk of preterm delivery to improve neonatal respiratory and mortality outcomes. The dose in current use has never been evaluated to minimize exposures while assuring efficacy. We report the pharmacokinetics and pharmacodynamics (PDs) of oral and intramuscular treatments with single 6 mg doses of dexamethasone phosphate, betamethasone phosphate, or a 1:1 mixture of betamethasone phosphate and betamethasone acetate in reproductive age South Asian women. Intramuscular or oral betamethasone has a terminal half-life of 11 hours, about twice as long as the 5.5 hours for oral and intramuscular dexamethasone. The 1:1 mixture of betamethasone phosphate and betamethasone acetate shows an immediate release of betamethasone followed by a slow release where plasma betamethasone can be measured out to 14 days after the single dose administration, likely from a depo formed at the injection site by the acetate. PD responses were: increased glucose, suppressed cortisol, increased neutrophils, and suppressed basophils, CD3CD4 and CD3CD8 lymphocytes. PD responses were comparable for betamethasone and dexamethasone, but with longer times to return to baseline for betamethasone. The 1:1 mixture of betamethasone phosphate and betamethasone acetate caused much longer adrenal suppression because of the slow release. These results will guide the development of better treatment strategies to minimize fetal and maternal drug exposures for women at risk of preterm delivery.
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Affiliation(s)
- Alan H. Jobe
- Division of Pulmonary BiologyCincinnati Children's Hospital Medical CenterUniversity of CincinnatiCincinnatiOhioUSA
| | - Mark A. Milad
- Milad Pharmaceutical Consulting LLCPlymouthMichiganUSA
| | | | - William J. Jusko
- State University of New YorkSchool of Pharmacy and Pharmaceutical SciencesUniversity of BuffaloBuffaloNew YorkUSA
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14
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Kemp MW, Saito M, Schmidt AF, Usuda H, Watanabe S, Sato S, Hanita T, Kumagai Y, Takahashi T, Musk GC, Furfaro L, Stinson L, Fee EL, Eddershaw PJ, Payne MS, Smallwood K, Bridges J, Newnham JP, Jobe AH. The duration of fetal antenatal steroid exposure determines the durability of preterm ovine lung maturation. Am J Obstet Gynecol 2020; 222:183.e1-183.e9. [PMID: 31494126 DOI: 10.1016/j.ajog.2019.08.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/14/2019] [Accepted: 08/23/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Antenatal corticosteroids (ACS) are the standard of care for maturing the fetal lung and improving outcomes for preterm infants. Antenatal corticosteroid dosing remains nonoptimized, and there is little understanding of how different treatment-to-delivery intervals may affect treatment efficacy. The durability of a lung maturational response is important because the majority of women treated with antenatal corticosteroids do not deliver within the widely accepted 1- to 7-day window of treatment efficacy. OBJECTIVE We used a sheep model to test the duration of fetal exposures for efficacy at delivery intervals from 1 to 10 days. MATERIALS AND METHODS For infusion studies, ewes with single fetuses were randomized to receive an intravenous bolus and maintenance infusion of betamethasone phosphate to target 1-4 ng/mL fetal plasma betamethasone for 36 hours, with delivery at 2, 4 ,or 7 days posttreatment or sterile saline solution as control. Animals receiving the clinical treatment were randomised to receive either a single injection of 0.25 mg/kg with a 1:1 mixture of betamethasone phosphate + betamethasone acetate with delivery at either 1 or 7 days posttreatment, or 2 treatments of 0.25 mg/kg betamethasone phosphate + betamethasone acetate spaced at 24 hours (giving ∼48 hours of fetal steroid exposure) with delivery at 2, 5, 7, or 10 days posttreatment. Negative control animals were treated with saline solution. All lambs were delivered at 121 ± 3 days gestational age and ventilated for 30 minutes to assess lung function. RESULTS Preterm lambs delivered at 1 or 2 days post-antenatal corticosteroid treatment had significant improvements in lung maturation for both intravenous and single-dose intramuscular treatments. After 2 days, the efficacy of 36-hour betamethasone phosphate infusions was lost. The single dose of 1:1 betamethasone phosphate + betamethasone acetate also was ineffective at 7 days. In contrast, animals treated with 2 doses had significant improvements in lung maturation at 2, 5, and 7 days, with treatment efficacy reduced by 10 days. CONCLUSION In preterm lambs, the durability of antenatal corticosteroids treatment depends on the duration of fetal exposure and is independent of the intravenous or intramuscular maternal route of administration. For acute 24- to 48-hour posttreatment deliveries, a 24-hour fetal antenatal corticosteroids exposure was sufficient for lung maturation. A fetal exposure duration of at least 48 hours was necessary to maintain long-term treatment durability. A single-dose ACS treatment should be sufficient for women delivering within <48 hours of antenatal corticosteroids treatment.
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Affiliation(s)
- Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia.
| | - Masatoshi Saito
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | | | - Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Shimpei Watanabe
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Shinichi Sato
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Takushi Hanita
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yusaku Kumagai
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Tsukasa Takahashi
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Gabrielle C Musk
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Lucy Furfaro
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Lisa Stinson
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | | | - Matthew S Payne
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Kiara Smallwood
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - James Bridges
- Cincinnati Children's Hospital Medical Centre, Cincinnati, OH
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Cincinnati Children's Hospital Medical Centre, Cincinnati, OH
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15
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Optimizing antenatal corticosteroid therapy for improving outcome of premature infants. Pediatr Res 2019; 86:556-557. [PMID: 31412354 DOI: 10.1038/s41390-019-0538-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 08/05/2019] [Indexed: 11/08/2022]
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16
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Schmidt AF, Kemp MW, Milad M, Miller LA, Bridges JP, Clarke MW, Kannan PS, Jobe AH. Oral dosing for antenatal corticosteroids in the Rhesus macaque. PLoS One 2019; 14:e0222817. [PMID: 31536601 PMCID: PMC6752828 DOI: 10.1371/journal.pone.0222817] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/06/2019] [Indexed: 02/04/2023] Open
Abstract
Antenatal corticosteroids (ACS) are standard of care for women at risk of preterm delivery, although choice of drug, dose or route have not been systematically evaluated. Further, ACS are infrequently used in low resource environments where most of the mortality from prematurity occurs. We report proof of principle experiments to test betamethasone-phosphate (Beta-P) or dexamethasone-phosphate (Dex-P) given orally in comparison to the clinical treatment with the intramuscular combination drug beta-phosphate plus beta-acetate in a Rhesus Macaque model. First, we performed pharmacokinetic studies in non-pregnant monkeys to compare blood levels of the steroids using oral dosing with Beta-P, Dex-P and an effective maternal intramuscular dose of the beta-acetate component of the clinical treatment. We then evaluated maternal and fetal blood steroid levels with limited fetal sampling under ultrasound guidance in pregnant macaques. We found that oral Beta is more slowly cleared from plasma than oral Dex. The blood levels of both drugs were lower in maternal plasma of pregnant than in non-pregnant macaques. Using the pharmacokinetic data, we treated groups of 6–8 pregnant monkeys with oral Beta-P, oral Dex-P, or the maternal intramuscular clinical treatment and saline controls and measured pressure-volume curves to assess corticosteroid effects on lung maturation at 5d. Oral Beta-P improved the pressure-volume curves similarly to the clinical treatment. Oral Dex-P gave more variable and nonsignificant responses. We then compared gene expression in the fetal lung, liver and hippocampus between oral Beta-P and the clinical treatment by RNA-sequencing. The transcriptomes were largely similar with small gene expression differences in the lung and liver, and no differences in the hippocampus between the groups. As proof of principle, ACS therapy can be effective using inexpensive and widely available oral drugs. Clinical dosing strategies must carefully consider the pharmacokinetics of oral Beta-P or Dex-P to minimize fetal exposure while achieving the desired treatment responses.
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Affiliation(s)
- Augusto F. Schmidt
- Department of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, United States of America
| | | | - Mark Milad
- Milad Pharmaceutical consulting LLC, Plymouth, Michigan, United States of America
| | - Lisa A. Miller
- California National Primate Research Center, University of California, Davis, Davis, California, United States of America
| | - James P. Bridges
- Department of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Michael W. Clarke
- Metabolomics Australia, Centre for Microscopy, Characterization and Analysis, The University of Western Australia, Perth, WA, Australia
| | - Paranthaman S. Kannan
- Department of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Alan H. Jobe
- Department of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, United States of America
- University of Western Australia, Perth, Australia
- * E-mail:
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