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Jensen EA, DeMauro SB, Rysavy MA, Patel RM, Laughon MM, Eichenwald EC, Do BT, Das A, Wright CJ. Acetaminophen for Patent Ductus Arteriosus and Risk of Mortality and Pulmonary Morbidity. Pediatrics 2024; 154:e2023065056. [PMID: 39011550 PMCID: PMC11291959 DOI: 10.1542/peds.2023-065056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 07/17/2024] Open
Abstract
OBJECTIVE Emerging data indicate that acetaminophen may adversely affect lung health. We examined whether acetaminophen compared with cyclooxygenase (COX) inhibitor alone for patent ductus arteriosus (PDA) is associated with mortality or respiratory morbidity in extremely preterm infants. METHODS This is a retrospective cohort study using data from the National Institute of Child Health and Human Development Neonatal Research Network. Infants were born at 22 to 28 weeks' gestation or weighing 401 to 1000 g between 2016 and 2020 and received acetaminophen, ibuprofen, and/or indomethacin for PDA closure. The primary outcome was death or grade 2 to 3 bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age. Secondary outcomes included predischarge mortality and respiratory morbidities. Risk ratios were adjusted for baseline and early postnatal factors. Additional exploratory analyses were adjusted for later postnatal covariates. RESULTS Of 1921 infants, 627 (32.6%) received acetaminophen and 1294 (67.3%) received COX inhibitor only. Multidrug therapy (42.9% vs 4.7%) and surgical or catheter PDA closure (26.5% vs 19.9%) were more common among acetaminophen-exposed infants. Death or grade 2 to 3 BPD at 36 weeks' postmenstrual age was similar between infants treated with acetaminophen versus COX inhibitor only (57.1% vs 58.3%; adjusted relative risk [aRR] 0.96, 95% confidence interval [CI] 0.87-1.06). Acetaminophen was associated with increased risk of predischarge mortality (13.3% vs 10.0%) when adjusting for perinatal and early postnatal factors (aRR 1.42, 95% CI 1.02-1.93), but not in exploratory analyses that included later postnatal factors (aRR 1.28, 95% CI 0.91-1.82). CONCLUSIONS Treatment with acetaminophen versus COX inhibitor alone for PDA was not associated with the composite outcome of death or BPD in extremely preterm infants. Our results support further evaluation of whether acetaminophen for PDA increases mortality.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology and Department of Pediatrics; Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara B. DeMauro
- Division of Neonatology and Department of Pediatrics; Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas
| | - Ravi M. Patel
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Matthew M. Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eric C. Eichenwald
- Division of Neonatology and Department of Pediatrics; Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Barbara T. Do
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, Children’s Hospital Colorado and University of Colorado School of Medicine
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Jensen EA, Laughon MM, DeMauro SB, Cotten CM, Do B, Carlo WA, Watterberg KL. Contributions of the NICHD neonatal research network to the diagnosis, prevention, and treatment of bronchopulmonary dysplasia. Semin Perinatol 2022; 46:151638. [PMID: 36085059 PMCID: PMC11075436 DOI: 10.1016/j.semperi.2022.151638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite improvements in the care and outcomes of infants born extremely preterm, bronchopulmonary dysplasia (BPD) remains a common and frustrating complication of prematurity. This review summarizes the BPD-focused research conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN). To improve disease classification and outcome prediction, the NRN developed new data-driven diagnostic criteria for BPD and web-based tools that allow clinicians and investigators to reliably estimate BPD risk in preterm infants. Randomized trials of intramuscular vitamin A and prophylactic nasal continuous positive airway pressure conducted by the NRN have contributed to our current use of these therapies as evidence-based approaches to reduce BPD risk. A recent large, randomized trial of hydrocortisone administered beginning between the 2nd and 4th postnatal weeks provided strong evidence that this therapy promotes successful extubation but does not lower BPD rates. Ongoing studies within the NRN will address important, unanswered questions on the risks and benefits of intratracheal surfactant/corticosteroid combinations and treatment versus expectant management of the patent ductus arteriosus to prevent BPD.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States.
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sara B DeMauro
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Barbara Do
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristi L Watterberg
- University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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Surak A, Jain A, Hyderi A. Different approaches for patent ductus arteriosus in premature infants using acetaminophen. World J Pediatr 2022; 18:243-250. [PMID: 35253098 DOI: 10.1007/s12519-022-00526-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acetaminophen use for pharmacological treatment of hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants is becoming more popular with emerging evidence that it is effective as well as safe alternative for other agents used to close hsPDA. DATA SOURCES We performed a narrative review of literature about pharmacological treatment of PDA using acetaminophen. RESULTS Acetaminophen was used as a prophylaxis, symptomatic, targeted, and a rescue approach. CONCLUSIONS It appears that acetaminophen could be used in different approaches to close the hsPDA. Long-term outcomes of acetaminophen exposure early in life still lack certainty.
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Affiliation(s)
- Aimann Surak
- Northern Alberta Neonatal Program Royal Alexandra Hospital Site NICU, DTC 5027, Stollery Children Hospital, University of Alberta, 10240 Kingsway NW, Edmonton, AB, T5H 3V9, Canada.
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Abbas Hyderi
- Northern Alberta Neonatal Program Royal Alexandra Hospital Site NICU, DTC 5027, Stollery Children Hospital, University of Alberta, 10240 Kingsway NW, Edmonton, AB, T5H 3V9, Canada
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Hundscheid T, El-Khuffash A, McNamara PJ, de Boode WP. Survey highlighting the lack of consensus on diagnosis and treatment of patent ductus arteriosus in prematurity. Eur J Pediatr 2022; 181:2459-2468. [PMID: 35305143 PMCID: PMC9110525 DOI: 10.1007/s00431-022-04441-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/02/2023]
Abstract
To gain insight in the availability of guidelines, diagnostic criteria, and treatment strategies and whether clinical equipoise regarding optimal treatment for patent ductus arteriosus (PDA) in prematurity is present. We hypothesized that (co-)authors of PDA-related papers were more likely to screen for a PDA and would treat earlier and more aggressively. An international internet-based survey between September 2019 and March 2020 in which we collected (1) baseline characteristics; (2) availability of guidelines; (3) screening strategy for PDA; (4) diagnostic criteria for hemodynamic significance; (5) treatment strategy; and (6) metrics of treatment efficacy. Finally, ten clinical equipoise statements were posed on a Likert scale. In total, 144 surveys were sent, of which 71/144 (49%) surveys could be analyzed with 56/71 (79%) fully completed surveys. The respondents, mainly neonatologists in a level III neonatal intensive care unit, of whom 36/71 (51%) had (co-)authored a publication on the PDA, highlighted a lack of national guidelines, heterogeneous approach to screening strategies, and marked variability in diagnostic criteria to assess hemodynamic significance, treatment strategies and effect measurement. No major significant differences were observed between respondents who did or did not (co-)author a publication on the PDA. Respondents who screened for PDA scored significantly higher on the need for screening, early and aggressive treatment. Remarkably, the scores of all statements regarding clinical equipoise varied widely. Conclusions: Our survey highlights the lack of guidelines and enormous heterogeneity in current practice. Current evidence is not robust enough to harmonize current treatment strategies into (inter)national guidelines. What is Known: • Patent ductus arteriosus (PDA) incidence is inversely related to gestational age. • Although early pharmacological treatment induces PDA closure, optimal treatment is debated due to the lack of beneficial effects on outcome. What is New: • In the absence of (inter)national guidelines, diagnostic and treatment strategies are heterogeneous and contradictory, even in a selected hemodynamically- interested group. • Different PDA screening strategies did, while PDA publication status did not, show significant differences in treatment strategy and responses to equipoise statements.
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Affiliation(s)
- Tim Hundscheid
- Department of Pediatrics, Division of Neonatology, Radboud Institute for Health Sciences, Amalia Children's Hospital, Radboud University Medical Center Nijmegen, Internal Postal Code 804, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Afif El-Khuffash
- grid.4912.e0000 0004 0488 7120Department of Neonatology, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Patrick J. McNamara
- grid.214572.70000 0004 1936 8294Departments of Pediatrics & Internal Medicine, Division of Neonatology, University of Iowa, Iowa City, IA USA
| | - Willem P. de Boode
- grid.461578.9Department of Pediatrics, Division of Neonatology, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Radboud University Medical Center Nijmegen, Internal Postal Code 804, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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Bauer-Rusek S, Samra N, Moore SS, Arnon S. Paracetamol Treatment for Patent Ductus Arteriosus, an Apparent Association with Acute Hemolysis in Three Preterm Infants: Case Series. Neonatology 2022; 119:530-534. [PMID: 35728580 DOI: 10.1159/000525128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/11/2022] [Indexed: 11/19/2022]
Abstract
We report three preterm infants who were treated with paracetamol for hemodynamically significant patent ductus arteriosus and developed acute hemolysis. No other apparent cause of acute hemolysis was found during Neonatal Intensive Care Unit hospitalization. All three infants were born within 1 year. As this side effect of paracetamol has not been reported previously and many preterm infants receive paracetamol for PDA closure, we advocate awareness. We cannot be sure whether the hemolysis occurred due to an underlying cause that was augmented by paracetamol or whether the drug itself caused acute hemolysis in these preterm infants.
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Affiliation(s)
- Sofia Bauer-Rusek
- Department of Neonatology, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nava Samra
- Department of Neonatology, Meir Medical Center, Kfar Saba, Israel
| | | | - Shmuel Arnon
- Department of Neonatology, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Population pharmacokinetic-pharmacodynamic modeling of acetaminophen in preterm neonates with hemodynamically significant patent ductus arteriosus. Eur J Pharm Sci 2021; 167:106023. [PMID: 34592463 DOI: 10.1016/j.ejps.2021.106023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/12/2021] [Accepted: 09/25/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pharmacokinetics (PK) of intravenous acetaminophen has not been assessed in preterm neonates with hemodynamically significant patent ductus arteriosus (PDA). Moreover, there is a lack of data evaluating the association between PK and pharmacodynamics (PD) of acetaminophen in hemodynamically significant PDA. Hence, we performed a population PK-PD modeling of acetaminophen in preterm neonates with hemodynamically significant PDA. METHODS A prospective, observational study was carried out in preterm neonates with hemodynamically significant PDA receiving intravenous acetaminophen (15 mg/kg six hourly) for maximum of nine days. The diameter of the ductus arteriosus was measured using General Electric Vivid 7® (echocardiography) and was the PD measure. The PK-PD modeling was performed using Monolix 2019R2. We performed Monte Carlo (MC) simulations to determine the probability of ductus arteriosus closure from first to the ninth day of acetaminophen treatment. RESULTS Fifty-five neonates were recruited. A one-compartment model with first-order elimination described well the PK of acetaminophen. Clearance (CL) and volume of distribution (Vd) for typical neonate weighing 0.98 kg was 0.0452 L/h and 1.18 L, respectively. A combination of an Imax model with effect compartment and an exponential disease progression model described well the PD of acetaminophen. The average baseline diameter of the ductus arteriosus (E0) was 2.53 mm while IC50 was 0.477 µg/mL. The disease progression rate constant (Kprog) and effect compartment transfer rate constant (ke0) were 0.00425 h-1 and 0.000103 h-1, respectively. MC simulations of the current dosing regimen revealed a probability of 73.7% ductus arteriosus closure compared to 83.8% with 20 mg/kg six hourly dose. CONCLUSION The PK-PD model developed can be used for dosing acetaminophen in premature neonates with hemodynamically significant PDA. Intravenous dose of 20 mg/kg intravenously every six hours is likely to provide a better therapeutic effect than the existing dosing regimen.
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Wright CJ. Acetaminophen and the Developing Lung: Could There Be Lifelong Consequences? J Pediatr 2021; 235:264-276.e1. [PMID: 33617854 PMCID: PMC9810455 DOI: 10.1016/j.jpeds.2021.02.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 01/05/2023]
Affiliation(s)
- Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
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Sridharan K, Al Jufairi M, Al Ansari E, Al Marzooq R, Hubail Z, Hasan SJR, Al Madhoob A. Intravenous acetaminophen (at 15 mg/kg/dose every 6 hours) in critically ill preterm neonates with patent ductus arteriosus: A prospective study. J Clin Pharm Ther 2021; 46:1010-1019. [PMID: 33638909 DOI: 10.1111/jcpt.13384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/24/2021] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Acetaminophen has been increasingly used in treating patent ductus arteriosus (PDA) in preterm neonates. Variations were observed in the dosing regimen of acetaminophen across the studies. There is hardly any data available for a relatively higher dose of intravenous acetaminophen (15 mg/kg/dose every 6 hours) in the preterm population. We present here the results of a prospective study with this dose of intravenous acetaminophen for treating PDA in critically ill preterm neonates. METHODS Preterm neonates (≤37 weeks of gestational age) with haemodynamically significant PDA were enrolled. Intravenous acetaminophen at 15 mg/kg/dose every 6 hours was administered. Echocardiographic monitoring, liver and renal function tests were carried out. Standard definitions were adhered for defining acute kidney injury (AKI) and hepatotoxicity. RESULTS Fifty-five neonates were recruited. Following the first dose, less than half had their serum acetaminophen concentrations in the therapeutic range. Extreme preterm neonates were less likely to have a sustained therapeutic acetaminophen concentration after the first dose. Following multiple doses and at steady state, 97.2% and 98.8% respectively were in the therapeutic range. Forty-three (78.2%) neonates had successful closure of the ductus arteriosus of which 22 were extreme preterm, 17 were very preterm and 4 were late preterm neonates; and considering their birthweights, 21 were extremely low, 16 were very low and 6 were low birthweight categories. Ten neonates had elevated alanine aminotransferase levels with three in the low-to-moderate risk of hepatotoxicity category. Eight neonates had altered renal function tests indicating AKI. WHAT IS NEW AND CONCLUSION Intravenous acetaminophen at 15 mg/kg/dose every 6 hours was efficacious in 78.2% of the preterm neonates with PDA. We observed a lower incidence of hepatotoxicity, and AKI in the study population. No association was observed between the serum acetaminophen concentrations and PDA closure.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Muna Al Jufairi
- Neonatology Intensive Care Unit, Department of Pediatrics, Salmaniya Medical Complex, Manama, Kingdom of Bahrain.,Department of Pediatrics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Eman Al Ansari
- Neonatology Intensive Care Unit, Department of Pediatrics, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Reem Al Marzooq
- Neonatology Intensive Care Unit, Department of Pediatrics, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Zakariya Hubail
- Department of Pediatrics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.,Department of Cardiology, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | | | - Abdulraoof Al Madhoob
- Neonatology Intensive Care Unit, Department of Pediatrics, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
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Is late treatment with acetaminophen safe and effective in avoiding surgical ligation among extremely preterm neonates with persistent patent ductus arteriosus? J Perinatol 2021; 41:2519-2525. [PMID: 34453113 PMCID: PMC8395383 DOI: 10.1038/s41372-021-01194-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/09/2021] [Accepted: 08/19/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Evaluate the association of late treatment with acetaminophen vs. immediate surgical ligation with death or neurodevelopmental impairment (NDI) among extremely low gestational age neonates (ELGANs) with persistent patent ductus arteriosus (pPDA). STUDY DESIGN Retrospective comparative epoch study of ELGANs with pPDA being considered for surgical ligation. ELGANs in epoch 1 (2009-2012) were referred for ligation, while infants in epoch 2 (2012-2015) were treated with oral acetaminophen and referred for ligation in the absence of improvement. The primary outcome was a composite of death/NDI at 18-24 months. RESULTS Ninety-two ELGANs with median[IQR] GA 25.2 weeks [24.4, 26.3] had pPDA (43 in epoch 1, 49 in -epoch 2) with acetaminophen-exposed neonates receiving 7 days [7, 7] of treatment. ELGANs in epoch 2 had reduced ligation (aOR 0.30; 95%CI: [0.11, 0.87]), but there was no difference in death/NDI (aOR 1.03; 95%CI: [0.30, 3.56]). CONCLUSIONS Late treatment with acetaminophen to avoid surgery for pPDA is associated with reduced ligation but no difference in death/NDI, supporting the safety and effectiveness of this approach.
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