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Mahoney L, Raffaeli G, Beken S, Ünal S, Kotidis C, Cavallaro G, Garrido F, Bhatt A, Dempsey EM, Allegaert K, Simons SHP, Flint RB, Smits A. Grading the level of evidence of neonatal pharmacotherapy: midazolam and phenobarbital as examples. Pediatr Res 2024; 95:75-83. [PMID: 37752246 DOI: 10.1038/s41390-023-02779-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/07/2023] [Accepted: 07/17/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Many drugs are used off-label or unlicensed in neonates. This does not mean they are used without evidence or knowledge. We aimed to apply and evaluate the Grading and Assessment of Pharmacokinetic-Pharmacodynamic Studies (GAPPS) scoring system for the level of evidence of two commonly used anti-epileptic drugs. METHODS Midazolam and phenobarbital as anti-epileptics were evaluated with a systematic literature search on neonatal pharmacokinetic (PK) and/or pharmacodynamic [PD, (amplitude-integrated) electroencephalography effect] studies. With the GAPPS system, two evaluators graded the current level of evidence. Inter-rater agreement was assessed for dosing evidence score (DES), quality of evidence (QoE), and strength of recommendation (REC). RESULTS Seventy-two studies were included. DES scores 4 and 9 were most frequently used for PK, and scores 0 and 1 for PD. Inter-rater agreements on DES, QoE, and REC ranged from moderate to very good. A final REC was provided for all PK studies, but only for 25% (midazolam) and 33% (phenobarbital) of PD studies. CONCLUSIONS There is a reasonable level of evidence concerning midazolam and phenobarbital PK in neonates, although using a predefined target without integrated PK/PD evaluation. Further research is needed on midazolam use in term neonates with therapeutic hypothermia, and phenobarbital treatment in preterms. IMPACT There is a reasonable level of evidence concerning pharmacotherapy of midazolam and phenobarbital in neonates. Most evidence is however based on PK studies, using a predefined target level or concentration range without integrated, combined PK/PD evaluation. Using the GAPPS system, final strength of recommendation could be provided for all PK studies, but only for 25% (midazolam) to 33% (phenobarbital) of PD studies. Due to the limited PK observations of midazolam in term neonates with therapeutic hypothermia, and of phenobarbital in preterm neonates these subgroups can be identified for further research.
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Affiliation(s)
- Liam Mahoney
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Genny Raffaeli
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Serdar Beken
- Section of Neonatology, Department of Pediatrics, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Sezin Ünal
- Department of Neonatology, Ankara Etlik City Hospital, University of Health Sciences, Ankara, Turkey
| | - Charalampos Kotidis
- Department of Women's and Children's Health, University of Liverpool, Liverpool Health Partners, Liverpool, UK
- University of Liverpool, Liverpool Womens Hospital, Liverpool, UK
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, OX3 9DU, UK
| | - Eugene M Dempsey
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Sinno H P Simons
- Division of Neonatology, Department of Neonatal and Pediatric Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
- Division of Neonatology, Department of Neonatal and Pediatric Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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Petkova V, Georgieva D, Dimitrov M, Nikolova I. Off-Label Prescribing in Pediatric Population-Literature Review for 2012-2022. Pharmaceutics 2023; 15:2652. [PMID: 38139994 PMCID: PMC10747118 DOI: 10.3390/pharmaceutics15122652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/05/2023] [Accepted: 11/17/2023] [Indexed: 12/24/2023] Open
Abstract
Off-label prescribing is widespread among pediatricians, and it is unlikely that this trend will soon be bound by a uniform legal framework. This is necessitated by the fact that there are four variables: the patient's health condition, the physician's experience and knowledge, the legislative measures (laws, directives, guidelines, and recommendations), and finally, the pharmaceutical industry. There is considerable concern worldwide about the use of off-label medicines in children. We may call it an enormous global problem that is much talked about and written about; however, we should not forget that the goal around which everyone should unite is the patient's life. For healthcare providers, the most important thing will always be the health and preservation of the patient's life, particularly when it comes to children with life-threatening conditions in neonatal and pediatric intensive care units (NICU and PICU). The study aimed to examine the prevalence of off-label drug use in pediatrics. Literature research was conducted, and we included studies from 2012 to 2022 that evaluated off-label drug prevalence in various pediatric patient populations.
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Affiliation(s)
- Valentina Petkova
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, 1000 Sofia, Bulgaria
| | - Dilyana Georgieva
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Medical University of Sofia, 1000 Sofia, Bulgaria; (D.G.); (M.D.)
| | - Milen Dimitrov
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Medical University of Sofia, 1000 Sofia, Bulgaria; (D.G.); (M.D.)
| | - Irina Nikolova
- Department of Pharmacology, Pharmacotherapy and Toxicology, Faculty of Pharmacy, Medical University of Sofia, 1000 Sofia, Bulgaria;
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Gade C, Trolle S, Mørk M, Lewis A, Andersen P, Jacobsen T, Andersen J, Lausten‐Thomsen U. Massive presence of off-label medicines in Danish neonatal departments: A nationwide survey using national hospital purchase data. Pharmacol Res Perspect 2023; 11:e01037. [PMID: 36545691 PMCID: PMC9772727 DOI: 10.1002/prp2.1037] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/06/2022] [Indexed: 12/24/2022] Open
Abstract
There is currently insufficient knowledge of gestational age dependent medicine disposition in neonates. Accordingly, the use of off-label medication, i.e., use of medicines outside its approved marketing authorization, is high in the neonatal departments. By using data from the Danish National Pharmaceutical Hospital Purchase Database, we identified the most commonly occurring medications and calculated the on/off-label ratios for premature and term neonates. Data was extracted on ATC level 5 and based on defined daily doses as per WHO. Data covered the 4 high-level NICUs and 10 of 13 of the intermediate/standard level Danish neonatal departments. Of the identified medication, 87% and 70% did not have approved marketing authorization for use in premature and full-term neonates, respectively. Furthermore, one-fifth of the top 100 medicines did not have a (Danish) marketing license. Overall, off-label medication was widespread covering virtually all ATC groups and no ATC group had an off-label level lower than 50% (range 50%-100%). Finally, in 21% of medications, additives from 8 different chemical groups with potential deleterious effects for neonates were identified. In conclusion, off-label medication in the Danish neonatal departments is widespread. The pharmaceutical industry is unlikely to solve this problem, and we may for a very long time be occasionally forced to use off-label medication. Practical solution must therefore come from multidisciplinary clinical and academic collaboration. Use of formulation list as guidance for prescriptions and NICU-friendly galenic formulations may mitigate the problem temporarily while waiting for definitive studies.
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Affiliation(s)
- Christina Gade
- Department of Clinical PharmacologyCopenhagen University Hospital Bispebjerg and FrederiksbergCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Stine Trolle
- The Hospital PharmacyCopenhagen University Hospital Capital region of DenmarkCopenhagenDenmark
| | - Mette‐Louise Mørk
- Department of Clinical PharmacologyCopenhagen University Hospital Bispebjerg and FrederiksbergCopenhagenDenmark
| | - Anna Lewis
- Department of NeonatologyCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Peter Fruergaard Andersen
- Department of Clinical PharmacologyCopenhagen University Hospital Bispebjerg and FrederiksbergCopenhagenDenmark
| | - Thorkild Jacobsen
- Department of NeonatologyCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Jon Andersen
- Department of Clinical PharmacologyCopenhagen University Hospital Bispebjerg and FrederiksbergCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Ulrik Lausten‐Thomsen
- Department of NeonatologyCopenhagen University Hospital RigshospitaletCopenhagenDenmark
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O'Connor TL. Premedication for Nonemergent Neonatal Intubation: A Systematic Review. J Perinat Neonatal Nurs 2022; 36:284-296. [PMID: 35894726 DOI: 10.1097/jpn.0000000000000613] [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] [Indexed: 11/26/2022]
Abstract
This systematic review evaluates research regarding the use of premedication for nonemergent neonatal intubation. Unmedicated intubation is associated with adverse outcomes such as physiologic instability and decompensation, repeat and prolonged intubation attempts, and trauma. Included studies compared medicated intervention groups against an unmedicated control. Medications vary greatly across studies and include anesthetics, opioids, benzodiazepines, barbiturates, vagolytics, and neuromuscular blockades (muscle relaxants). A comprehensive search of randomized control trials, retrospective cohort studies, and prospective observational studies was completed from the electronic databases of CINAHL EBSCOhost, Ovid MEDLINE, PubMed, EMBASE, Google Scholar, Cochrane Collaboration, and ClinicalTrials.gov and footnotes were used to complete the search. Twelve studies are included in this review dating back to 1984 and are from 5 countries. Outcome measures include changes in heart rate, oxygen saturation, and blood pressure; number and duration of attempts to intubate; and trauma to the oral cavity and upper airway. Twelve studies are included in this review and include 5410 patients. No studies were excluded based on level of evidence or quality appraisal. Findings in this review support the recommendation that opioids and vagolytic agents should be used for premedication for nonemergent neonatal intubation and adjuvant sedation and muscle relaxants should be considered.
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Same baby, different care: variations in practice between neonatologists and pediatric intensivists. Eur J Pediatr 2022; 181:1669-1677. [PMID: 35006378 DOI: 10.1007/s00431-022-04372-4] [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: 10/25/2021] [Revised: 12/20/2021] [Accepted: 01/02/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED The aim of the study was to identify and explore areas in neonatal care in which significant differences in clinical care exist, among neonatal intensive care (NICU) and pediatric intensive care (PICU) physicians. A questionnaire presenting three common scenarios in neonatal critical care-severe pneumonia, post-cardiac-surgery care, and congenital diaphragmatic hernia (CDH) was electronically sent to all PICU and NICU physicians in Israel. The survey was completed by 110 physicians. Significant differences were noted between NICU and PICU physicians' treatment choices. A non-cuffed endotracheal tube, initial high-frequency ventilation, and lower tidal volumes when applying synchronized-intermittent-mechanical-ventilation were selected more often by NICU physicians. For sedation/analgesia, NICU physicians treated as needed or by continuous infusion of a single agent, while PICU physicians more often chose to continuously infuse ≥ 2 medications. Fentanyl, midazolam, and muscle relaxants were chosen more often by PICU physicians. Morphine administration was similar for both groups. Treating CDH with pulmonary hypertension and systemic hypotension, NICU physicians more often began treatment with high dose dopamine and/or dobutamine, while PICU physicians chose low-dose adrenalin and/or milrinone. For vascular access NICU physicians chose umbilical lines most often, while PICU physicians preferred other central sites. CONCLUSION Our study identified major differences in respiratory and hemodynamic care, sedation and analgesia, and vascular access between NICU and PICU physicians, resulting from field-specific consensus guidelines and practice traditions. We suggest to establish joint committees from both professions, aimed at finding the optimal treatment for this vulnerable population - be it in the NICU or in the PICU. WHAT IS KNOWN • Variability in neonatal care between the neonatal and the pediatric intensive care units has been previously described. WHAT IS NEW • This scenario-based survey study identified major differences in respiratory and hemodynamic care, sedation and analgesia, and vascular access between neonatologists and pediatric intensivists, resulting from lack of evidence-based literature to guide neonatal care, field-specific consensus guidelines, and practice traditions. • These findings indicate a need for joint committees, combining the unique skills and literature from both professions, to conduct clinical trials focusing on these specific areas of care, aimed at finding the optimal treatment for this vulnerable population - be it in the neonatal or the pediatric intensive care unit.
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Knowledge gaps in late-onset neonatal sepsis in preterm neonates: a roadmap for future research. Pediatr Res 2022; 91:368-379. [PMID: 34497356 DOI: 10.1038/s41390-021-01721-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022]
Abstract
Late-onset neonatal sepsis (LONS) remains an important threat to the health of preterm neonates in the neonatal intensive care unit. Strategies to optimize care for preterm neonates with LONS are likely to improve survival and long-term neurocognitive outcomes. However, many important questions on how to improve the prevention, early detection, and therapy for LONS in preterm neonates remain unanswered. This review identifies important knowledge gaps in the management of LONS and describe possible methods and technologies that can be used to resolve these knowledge gaps. The availability of computational medicine and hypothesis-free-omics approaches give way to building bedside feedback tools to guide clinicians in personalized management of LONS. Despite advances in technology, implementation in clinical practice is largely lacking although such tools would help clinicians to optimize many aspects of the management of LONS. We outline which steps are needed to get possible research findings implemented on the neonatal intensive care unit and provide a roadmap for future research initiatives. IMPACT: This review identifies knowledge gaps in prevention, early detection, antibiotic, and additional therapy of late-onset neonatal sepsis in preterm neonates and provides a roadmap for future research efforts. Research opportunities are addressed, which could provide the means to fill knowledge gaps and the steps that need to be made before possible clinical use. Methods to personalize medicine and technologies feasible for bedside clinical use are described.
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Kort EHM, Simons SHP, Weissenbruch MM. Reply to Letter 'Propofol in preterm neonates'. Acta Paediatr 2021; 110:1693. [PMID: 33445209 DOI: 10.1111/apa.15755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ellen H. M. Kort
- Division of Neonatology Department of Pediatrics Máxima Medical Center Veldhoven The Netherlands
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children’s Hospital Rotterdam The Netherlands
| | - Sinno H. P. Simons
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children’s Hospital Rotterdam The Netherlands
| | - Mirjam M. Weissenbruch
- Division of Neonatology Department of Pediatrics Amsterdam UMC location VU University Medical Center Amsterdam The Netherlands
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van Hoorn CE, Flint RB, Skowno J, Davies P, Engelhardt T, Lalwani K, Olutoye O, Ista E, de Graaff JC. Off-label use of dexmedetomidine in paediatric anaesthesiology: an international survey of 791 (paediatric) anaesthesiologists. Eur J Clin Pharmacol 2021; 77:625-635. [PMID: 33119787 PMCID: PMC7935836 DOI: 10.1007/s00228-020-03028-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 10/15/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE The purpose of this international study was to investigate prescribing practices of dexmedetomidine by paediatric anaesthesiologists. METHODS We performed an online survey on the prescription rate of dexmedetomidine, route of administration and dosage, adverse drug reactions, education on the drug and overall experience. Members of specialist paediatric anaesthesia societies of Europe (ESPA), New Zealand and Australia (SPANZA), Great Britain and Ireland (APAGBI) and the USA (SPA) were consulted. Responses were collected in July and August 2019. RESULTS Data from 791 responders (17% of 5171 invitees) were included in the analyses. Dexmedetomidine was prescribed by 70% of the respondents (ESPA 53%; SPANZA 69%; APAGBI 34% and SPA 96%), mostly for procedural sedation (68%), premedication (46%) and/or ICU sedation (46%). Seventy-three percent had access to local or national protocols, although lack of education was the main reason cited by 26% of the respondents not to prescribe dexmedetomidine. The main difference in dexmedetomidine use concerned the age of patients (SPA primarily < 1 year, others primarily > 1 year). The dosage varied widely ranging from 0.2-5 μg kg-1 for nasal premedication, 0.2-8 μg kg-1 for nasal procedural sedation and 0-4 μg kg-1 intravenously as adjuvant for anaesthesia. Only ESPA members (61%) had noted an adverse drug reaction, namely bradycardia. CONCLUSION The majority of anaesthesiologists use dexmedetomidine in paediatrics for premedication, procedural sedation, ICU sedation and anaesthesia, despite the off-label use and sparse evidence. The large intercontinental differences in prescribing dexmedetomidine call for consensus and worldwide education on the optimal use in paediatric practice.
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Affiliation(s)
- Camille E van Hoorn
- Department of Anaesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands.
- Department of Paediatric Surgery, Erasmus University Medical Centre -Sophia Children's Hospital, PO Box: 2060, 3000 CB, Rotterdam, The Netherlands.
| | - Robert B Flint
- Division of Neonatology, Department of Paediatrics, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Justin Skowno
- Department of Anaesthesiology, Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Paul Davies
- Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, Australia
| | - Thomas Engelhardt
- Department of Anaesthesia, Royal Children's Hospital Aberdeen and School of Medicine, University of Aberdeen, Aberdeen, UK
- Department of Anaesthesia, McGill University Health Center, Montreal Children's Hospital, Montreal, QC, Canada
| | - Kirk Lalwani
- Department of Anaesthesiology and Paediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Olutoyin Olutoye
- Department of Anaesthesiology, Peri-operative and Pain Medicine, Texas Children's Hospital, Houston, TX, 77030, USA
| | - Erwin Ista
- Department of Internal Medicine - Nursing Science, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Paediatric Surgery, Paediatric Intensive Care, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
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O'Connor TL. Premedication for Nonemergent Intubation in the NICU: A Call for Standardized Practice. Neonatal Netw 2021; 40:8-13. [PMID: 33479006 DOI: 10.1891/0730-0832/11-t-668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 11/25/2022]
Abstract
This paper discusses neonatal endotracheal intubation and the need for standardization in practice regarding the use of premedication. Intubation is common in the NICU because of resuscitation, surfactant administration, congenital anomalies, apnea, and sedation for procedures or surgery. Intubation is both painful and stressful. Unmedicated intubation is associated with several adverse outcomes including repeat and prolonged attempts, airway trauma, bradycardia, severe desaturation, and need for resuscitation. Most providers believe intubation is painful and that premedication should be provided; however, there is still resistance to provide premedication and inconsistency in doing so. Reasons for not providing premedication include concerns about medication side effects such as chest wall rigidity or prolonged respiratory depression inhibiting immediate extubation after surfactant administration. Premedication should include an opioid analgesic for pain, a benzodiazepine for an adjuvant sedation, a vagolytic to decrease bradycardia, and the optional use of a muscle relaxant for paralysis.
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Kort EHM, Twisk JWR, t Verlaat EPG, Reiss IKM, Simons SHP, Weissenbruch MM. Propofol in neonates causes a dose-dependent profound and protracted decrease in blood pressure. Acta Paediatr 2020; 109:2539-2546. [PMID: 32248549 PMCID: PMC7754147 DOI: 10.1111/apa.15282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 12/01/2022]
Abstract
AIM To analyse the effects of different propofol starting doses as premedication for endotracheal intubation on blood pressure in neonates. METHODS Neonates who received propofol starting doses of 1.0 mg/kg (n = 30), 1.5 mg/kg (n = 23) or 2.0 mg/kg (n = 26) as part of a previously published dose-finding study were included in this analysis. Blood pressure in the 3 dosing groups was analysed in the first 60 minutes after start of propofol. RESULTS Blood pressure declined after the start of propofol in all 3 dosing groups and was not restored 60 minutes after the start of propofol. The decline in blood pressure was highest in the 2.0 mg/kg dosing group. Blood pressure decline was mainly dependent on the initial propofol starting dose rather than the cumulative propofol dose. CONCLUSION Propofol causes a dose-dependent profound and prolonged decrease in blood pressure. The use of propofol should be carefully considered. When using propofol, starting with a low dose and titrating according to sedative effect seems the safest strategy.
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Affiliation(s)
- Ellen H. M. Kort
- Division of Neonatology Department of Pediatrics Máxima Medical Center Veldhoven The Netherlands
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Jos W. R. Twisk
- Department of Epidemiology and Biostatistics Amsterdam UMC Location VU University Medical Center Amsterdam The Netherlands
| | - Ellen P. G. t Verlaat
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Irwin K. M. Reiss
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Sinno H. P. Simons
- Division of Neonatology Department of Pediatrics Erasmus UMC – Sophia Children's Hospital Rotterdam The Netherlands
| | - Mirjam M. Weissenbruch
- Division of Neonatology Department of Pediatrics Amsterdam UMC Location VU University Medical Center Amsterdam The Netherlands
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Slater R, Moultrie F, Bax R, van den Anker J, Bhatt A. Preterm health: time to bridge the evidence gap. Lancet 2020; 396:872-873. [PMID: 32979963 DOI: 10.1016/s0140-6736(20)31977-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK.
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Ralph Bax
- Paediatric Medicines Office, Scientific Evidence Generation Department, European Medicines Agency, Amsterdam, Netherlands
| | - John van den Anker
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA; Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
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Drug Utilisation and Off-Label Use on a German Neonatal Intensive Care Unit: A Retrospective Cohort Study and 10-Year Comparison. PHARMACY 2020; 8:pharmacy8030173. [PMID: 32957455 PMCID: PMC7559028 DOI: 10.3390/pharmacy8030173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/17/2022] Open
Abstract
Pharmacotherapy of neonates is complex and marked to a large extent of off-label use. The implementation of the Paediatric Regulation (2007) gave hope for a change in the safety and efficacy for drugs used in neonatal intensive care units (NICU). This study investigates drug utilisation patterns and off-label use in a German neonatal intensive care unit (NICU) in 2014. A 12-months retrospective, observational cohort study was performed at the NICU of the University Children's Hospital Erlangen, Germany. Licensing status was determined using the Summary of Product Characteristics (SmPC). Results are compared with a similar study conducted 10 years earlier. The study included 204 patients (57.8% male) (2004: 183) and 2274 drug prescriptions were recorded (2004: 1978). The drugs that were mostly prescribed were drugs for the nervous system (2004: 22.6%; 2014: 26.9%) and anti-infectives for systemic use (2004: 26.0%; 2014: 24.9%);34.3% (2004) and 39.2% (2014) of all prescriptions were off-label;62.7% of all patients received at least one off-label or unlicensed drug (2004: 70%). For 13 drugs, the licensing status changed either from off-label to label (n = 9) or vice versa (n = 4). Overall, there was no significant change neither in terms of the drugs used nor regarding their licensing status. Further studies are needed to validate these findings in a European context.
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de Kort EH, Prins SA, Reiss IK, Willemsen SP, Andriessen P, van Weissenbruch MM, Simons SH. Propofol for endotracheal intubation in neonates: a dose-finding trial. Arch Dis Child Fetal Neonatal Ed 2020; 105:489-495. [PMID: 31932363 PMCID: PMC7547906 DOI: 10.1136/archdischild-2019-318474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/21/2019] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To find propofol doses providing effective sedation without side effects in neonates of different gestational ages (GA) and postnatal ages (PNA). DESIGN AND SETTING Prospective multicentere dose-finding study in 3 neonatal intensive care units. PATIENTS Neonates with a PNA <28 days requiring non-emergency endotracheal intubation. INTERVENTIONS Neonates were stratified into 8 groups based on GA and PNA. The first 5 neonates in every group received a dose of 1.0 mg/kg propofol. Based on sedative effect and side effects, the dose was increased or decreased in the next 5 patients until the optimal dose was found. MAIN OUTCOME MEASURES The primary outcome was the optimal single propofol starting dose that provides effective sedation without side effects in each age group. RESULTS After inclusion of 91 patients, the study was prematurely terminated because the primary outcome was only reached in 13% of patients. Dose-finding was completed in 2 groups, but no optimal propofol dose was found. Effective sedation without side effects was achieved more often after a starting dose of 2.0 mg/kg (28%) than after 1.0 mg/kg (3%) and 1.5 mg/kg (9%). Propofol-induced hypotension occurred in 59% of patients. Logistic regression analyses showed that GA and PNA did not predict effective sedation or the occurrence of hypotension. CONCLUSIONS Effective sedation without side effects is difficult to achieve with propofol and the optimal dose in different age groups of neonates could not be determined. The sedative effect of propofol and the occurrence of hypotension are unpredictable and show large inter-individual variability in the neonatal population.
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Affiliation(s)
- Ellen H.M. de Kort
- Neonatology, Maxima Medical Center, Veldhoven, The Netherlands,Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sandra A. Prins
- Neonatology, Amsterdam UMC location VU Medical Center, Amsterdam, The Netherlands
| | - Irwin K.M. Reiss
- Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | | | | | - Sinno H.P. Simons
- Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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14
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Al-Turkait A, Szatkowski L, Choonara I, Ojha S. Review of Drug Utilization Studies in Neonatal Units: A Global Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E5669. [PMID: 32764503 PMCID: PMC7459677 DOI: 10.3390/ijerph17165669] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
Abstract
Rational prescribing is challenging in neonatology. Drug utilization studies help identify and define the problem. We performed a review of the literature on drug use in neonatal units and describe global variations. We searched databases (EMBASE, CINAHL and Medline) from inception to July 2020, screened studies and extracted relevant data (two reviewers). The search revealed 573 studies of which 84 were included. India (n = 14) and the USA (n = 13) reported the most. Data collection was prospective (n = 56) and retrospective (n = 26), mostly (n = 52) from one center only. Sixty studies described general drug use in 34 to 450,386 infants (median (IQR) 190 (91-767)) over a median (IQR) of 6 (3-18) months. Of the participants, 20-87% were preterm. The mean number of drugs per infant (range 11.1 to 1.7, pooled mean (SD) 4 (2.4)) was high with some reporting very high burden (≥30 drugs per infant in 8 studies). This was not associated with the proportion of preterm infants included. Antibiotics were the most frequently used drug. Drug use patterns were generally uniform with some variation in antibiotic use and more use of phenobarbitone in Asia. This study provides a global perspective on drug utilization in neonates and highlights the need for better quality information to assess rational prescribing.
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Affiliation(s)
- Asma Al-Turkait
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (A.A.-T.); (I.C.)
| | - Lisa Szatkowski
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK;
| | - Imti Choonara
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (A.A.-T.); (I.C.)
| | - Shalini Ojha
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (A.A.-T.); (I.C.)
- Neonatal Unit, University Hospitals of Derby and Burton NHS Trust, Derby DE22 3NE, UK
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15
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Dosing of Antimicrobials in the Neonatal Intensive Care Unit: Does Clinical Practice Reflect Pharmacokinetics-based Recommendations? Pediatr Infect Dis J 2020; 39:713-717. [PMID: 32677811 DOI: 10.1097/inf.0000000000002657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We sought to compare meropenem and fluconazole dosing in the neonatal intensive care unit with recommendations based on published pharmacokinetic (PK) studies in infants. METHODS We performed an observational cohort study of infants <90 days postnatal age who received a course of meropenem or fluconazole who were treated in neonatal intensive care units managed by the Pediatrix Medical Group (1997-2016). We defined any dose amount from 80% to 120% of the published recommendation to constitute an appropriate dose of either antimicrobial. We calculated the percentage of appropriately dosed courses overall and by discharge year. We then evaluated the change in appropriate dosing over time using a nonparametric test of trend to evaluate the proportion of appropriately dosed courses of each antimicrobial by discharge year. RESULTS A total of 3608 infants were administered 2025 courses of meropenem and 1201 courses of fluconazole. Of all meropenem courses, 32% were dosed appropriately (increased significantly over time; P = 0.01), while 17% of fluconazole courses were dosed appropriately (increased significantly over time; P = 0.01). Median dosing for both meropenem and fluconazole was at or below recommendations; therefore, under-dosing was more common. CONCLUSIONS There was marked discordance between actual fluconazole and meropenem dosing and dosing recommendation in PK publications, yet adherence to PK-based doses showed improvement over time.
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16
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Poppe JA, van Weteringen W, Sebek LLG, Knibbe CAJ, Reiss IKM, Simons SHP, Flint RB. Precision Dosing of Doxapram in Preterm Infants Using Continuous Pharmacodynamic Data and Model-Based Pharmacokinetics: An Illustrative Case Series. Front Pharmacol 2020; 11:665. [PMID: 32477133 PMCID: PMC7236770 DOI: 10.3389/fphar.2020.00665] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/23/2020] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Current drug dosing in preterm infants is standardized, mostly based on bodyweight. Still, covariates such as gestational and postnatal age may importantly alter pharmacokinetics and pharmacodynamics. Evaluation of drug therapy in these patients is very difficult because objective pharmacodynamic parameters are generally lacking. By integrating continuous physiological data with model-based drug exposure and data on adverse drug reactions (ADRs), we aimed to show the potential benefit for optimized individual pharmacotherapy. MATERIALS AND METHODS Continuous data on oxygen saturation (SpO2), fraction of inspired oxygen (FiO2) and composite parameters, including the SpO2/FiO2 ratio and the cumulative oxygen shortage under the 89% SpO2 limit, served as indicators for doxapram effectiveness. We analyzed these continuous effect data, integrated with doxapram exposure and ADR parameters, obtained in preterm infants around the start of doxapram therapy. The exposures to doxapram and the active metabolite keto-doxapram were simulated using a population pharmacokinetic model. Infants were selected and retrospectively compared on the indication to start doxapram, the first response to doxapram, a potential dose-response relationship, and the administered dosage over time. Recommendations were made for individual improvements of therapy. RESULTS We provide eight cases of continuous doxapram administration that illustrate a correct and incorrect indication to start doxapram, responders and non-responders to therapy, and unnecessary over-exposure with ADRs. Recommendations for improvement of therapy include: objective evaluation of added effect of doxapram after start, prevention of overdosing by earlier down-titration or termination of therapy, and the prevention of hypoxia and agitation by measuring specific parameters at strategical time-points. CONCLUSION Real-time and non-invasive effect monitoring of drug therapy combined with model-based exposure provides relevant information to clinicians and can importantly improve therapy. The variability between and within patients emphasizes the importance of individual, objective evaluation of pharmacotherapy. These measurements, together with data on ADRs, allow for precision medicine in neonatology that should be brought to the bedside.
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Affiliation(s)
- Jarinda A. Poppe
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Willem van Weteringen
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Pediatric Surgery, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lotte L. G. Sebek
- Department of Hospital Pharmacy, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Catherijne A. J. Knibbe
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Irwin K. M. Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sinno H. P. Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Robert B. Flint
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
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17
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Gidey MT, Gebretsadkan YG, Tsadik AG, Welie AG, Assefa BT. Off-label and unlicensed drug use in Ayder comprehensive specialized hospital neonatal intensive care unit. Ital J Pediatr 2020; 46:41. [PMID: 32245504 PMCID: PMC7118957 DOI: 10.1186/s13052-020-0809-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 03/25/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Off- label drug use refers to the use of medicines outside of their marketing authorization with respect to dose, dosage form, route of administration, indication or age. Off-label/unlicensed drug use significantly associated with adverse drug reactions and medication errors in neonates and critically ill neonates are more vulnerable to these problems. OBJECTIVE To assess the prevalence and associated factors with off-label and unlicensed drug use in neonatal intensive care unit of Ayder Comprehensive Specialized Hospital. METHODS A cross-sectional study was conducted from March 01,2019 to April 30, 2019 in neonatal intensive care unit of Ayder Comprehensive Specialized Hospital. Neonates admitted for 24 h and took at least one medicine were included in the study. Data was collected from prescription and medical charts. The off-label and license status of the medicine was verified based on European medicine Agency electronic medicine compendium. Data was analyzed by SPSS version 21.0. Binary and multivariate logistic regression was done to assess the predictors of off-label/unlicensed medicine use at p-value ≤0.05 significance level. RESULT A total of 364 medicines prescribed for 122 neonates were analyzed. The prevalence of off-label and unlicensed drug use was 246 (67.58%), and 86 (23.63%) respectively. Of the total 122 neonates, 114(93.44%), and 57(46.72%) of them were exposed to at least one off-label and unlicensed drug respectively. Antibiotics were the most commonly prescribed off-label and unlicensed drugs. No statistically significant association was found between demographic as well as health related variables with off-label/unlicensed medicine use at p-value of ≤0.05 significance level. CONCLUSION Off-label and unlicensed medicine use was high among neonates admitted to intensive care unit of the hospital. Selecting the safest medicines for such vulnerable patients is crucial to promote rational prescribing and better therapeutic benefit.
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Affiliation(s)
- Meles Tekie Gidey
- Pharmacoepidemiology and Social pharmacy Course and Research Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
| | - Yohannes Gebrehaweria Gebretsadkan
- Pharmacoepidemiology and Social pharmacy Course and Research Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Afewerki Gebremeskel Tsadik
- Department of Clinical Pharmacy School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Abraham Gebrezgabiher Welie
- Pharmacoepidemiology and Social pharmacy Course and Research Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Brhane Teklebrhan Assefa
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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18
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Davis JM, Baer GR, McCune S, Klein A, Sato J, Fabbri L, Mangili A, Short MA, Tansey S, Mangum B, Hokuto I, Nakamura H, Salaets T, Allegaert K, Yao L, Blum M, Toerner J, Turner M, Portman R. Standardizing Safety Assessment and Reporting for Neonatal Clinical Trials. J Pediatr 2020; 219:243-249.e1. [PMID: 31708158 PMCID: PMC7096275 DOI: 10.1016/j.jpeds.2019.09.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Jonathan M Davis
- The Floating Hospital for Children at Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Boston, MA.
| | - Gerri R Baer
- US Food and Drug Administration, Office of Pediatric Therapeutics, Silver Spring, MD
| | - Susan McCune
- US Food and Drug Administration, Office of Pediatric Therapeutics, Silver Spring, MD
| | | | - Junko Sato
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | | | | | | | - Susan Tansey
- Independent Consultant Pharmaceutical Physician, Durham, NC
| | | | | | | | - Thomas Salaets
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Lynne Yao
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD
| | - Michael Blum
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD
| | - Joseph Toerner
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD
| | - Mark Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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19
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Mesek I, Nellis G, Lass J, Metsvaht T, Varendi H, Visk H, Turner MA, Nunn AJ, Duncan J, Lutsar I. Medicines prescription patterns in European neonatal units. Int J Clin Pharm 2019; 41:1578-1591. [PMID: 31625122 DOI: 10.1007/s11096-019-00923-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
Background Hospitalized neonates receive the highest number of drugs compared to all other age groups, but consumption rates vary between studies depending on patient characteristics and local practices. There are no large-scale international studies on drug use in neonatal units. Objective We aimed to describe drug use in European neonatal units and characterize its associations with geographic region and gestational age. Setting A one-day point prevalence study was performed as part of the European Study of Neonatal Exposure to Excipients from January to June 2012. Method All neonatal prescriptions and demographic data were registered in a web-based database. The impact of gestational age and region on prescription rate were analysed with logistic regression. Main outcome measure The number and variety of drugs prescribed to hospitalized neonates in different gestational age groups and geographic regions. Results In total, 21 European countries with 89 neonatal units participated. Altogether 2173 prescriptions given to 726 neonates were registered. The 10 drugs with the highest prescription rate were multivitamins, vitamin D, caffeine, gentamicin, amino acids for parenteral nutrition, phytomenadione, ampicillin, benzylpenicillin, fat emulsion for parenteral nutrition and probiotics. The six most commonly prescribed ATC groups (alimentary tract and metabolism, blood and blood-forming organs, systemic anti-infectives, nervous, respiratory and cardiovascular system) covered 98% of prescriptions. Gestational age significantly affected the use of all commonly used drug groups. Geographic region influenced the use of alimentary tract and metabolism, blood and blood-forming organs, systemic anti-infectives, nervous and respiratory system drugs. Conclusion While gestational age-dependent differences in neonatal drug use were expected, regional variations (except for systemic anti-infectives) indicate a need for cooperation in developing harmonized evidence-based guidelines and suggest priorities for collaborative work.
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Affiliation(s)
- Inge Mesek
- Department of Microbiology, University of Tartu, Tartu, Estonia.
| | - Georgi Nellis
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Neonatal Unit, Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Jana Lass
- Department of Microbiology, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Tuuli Metsvaht
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Clinic of Anaesthesiology and Intensive Care, Paediatric Intensive Care Unit, Tartu University Hospital, Tartu, Estonia
| | - Heili Varendi
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Neonatal Unit, Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Helle Visk
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Anthony J Nunn
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jennifer Duncan
- Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
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20
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Gouyon B, Martin-Mons S, Iacobelli S, Razafimahefa H, Kermorvant-Duchemin E, Brat R, Caeymaex L, Couringa Y, Alexandre C, Lafon C, Ramful D, Bonsante F, Binson G, Flamein F, Moussy-Durandy A, Di Maio M, Mazeiras G, Girard O, Desbruyeres C, Mourdie J, Escourrou G, Flechelles O, Abasse S, Rosenthal JM, Pages AS, Dorsi M, Karaoui L, ElGellab A, Le Bail Dantec F, Yangui MA, Norbert K, Kugbe Y, Lorrain S, Pignolet A, Garnier EM, Lapillonne A, Mitanchez D, Jacqz-Aigrain E, Gouyon JB. Characteristics of prescription in 29 Level 3 Neonatal Wards over a 2-year period (2017-2018). An inventory for future research. PLoS One 2019; 14:e0222667. [PMID: 31536560 PMCID: PMC6752821 DOI: 10.1371/journal.pone.0222667] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022] Open
Abstract
Objectives The primary objective of this study is to determine the current level of patient medication exposure in Level 3 Neonatal Wards (L3NW). The secondary objective is to evaluate in the first month of life the rate of medication prescription not cited in the Summary of Product Characteristics (SmPC). A database containing all the medication prescriptions is collected as part of a prescription benchmarking program in the L3NW. Material and methods The research is a two-year observational cohort study (2017–2018) with retrospective analysis of medications prescribed in 29 French L3NW. Seventeen L3NW are present since the beginning of the study and 12 have been progressively included. All neonatal units used the same computerized system of prescription, and all prescription data were completely de-identified within each hospital before being stored in a common data warehouse. Results The study population includes 27,382 newborns. Two hundred and sixty-one different medications (International Nonproprietary Names, INN) were prescribed. Twelve INN (including paracetamol) were prescribed for at least 10% of patients, 55 for less than 10% but at least 1% and 194 to less than 1%. The lowest gestational ages (GA) were exposed to the greatest number of medications (18.0 below 28 weeks of gestation (WG) to 4.1 above 36 WG) (p<0.0001). In addition, 69.2% of the 351 different combinations of an medication INN and a route of administration have no indication for the first month of life according to the French SmPC. Ninety-five percent of premature infants with GA less than 32 weeks received at least one medication not cited in SmPC. Conclusion Neonates remain therapeutic orphans. The consequences of polypharmacy in L3NW should be quickly assessed, especially in the most immature infants.
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Affiliation(s)
- Béatrice Gouyon
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | - Séverine Martin-Mons
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | - Silvia Iacobelli
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | | | | | - Roselyne Brat
- Centre Hospitalier Régional d’Orléans, Orléans, France
| | | | - Yvan Couringa
- Centre Hospitalier Andrée-Rosemon, Guyane Française, France
| | | | | | - Duksha Ramful
- Centre Hospitalier Universitaire de La Réunion – Site Nord, Saint Denis, Réunion, France
| | - Francesco Bonsante
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | | | | | | | | | - Gaël Mazeiras
- Centre Hospitalier de la Côte Basque, Bayonne, France
| | | | | | - Julien Mourdie
- Hôpital Jacques Monod – Groupe Hospitalier du Havre, Montivilliers, France
| | | | - Olivier Flechelles
- Centre Hospitalier Universitaire de Fort-de-France, Fort de France, Martinique, France
| | | | | | - Anne-Sophie Pages
- Centre Hospitalier Public du Cotentin, Cherbourg-en-Cotentin, France
| | - Marine Dorsi
- Centre Hospitalier Territorial Gaston-Bourret, Dumbéa, Nouvelle Calédonie, France
| | | | | | | | | | | | - Yaovi Kugbe
- Centre Hospitalier de l’Ouest Guyanais – Franck Joly, Saint Laurent du Maroni, Guyane Française, France
| | - Simon Lorrain
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | - Anaelle Pignolet
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | - Elodie Marie Garnier
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | | | | | | | - Jean-Bernard Gouyon
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
- * E-mail:
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Abstract
The beginnings of caring for critically ill patients date back to Florence Nightingale's work during the Crimean War in 1854, but the subspecialty of critical care medicine is relatively young. The first US multidisciplinary intensive care unit (ICU) was established in 1958, and the American Board of Medical Subspecialties first recognized the subspecialty of critical care medicine in 1986. Critical care pharmacy services began around the 1970s, growing in the intervening 40 years to become one of the largest practice areas for clinical pharmacists, with its own section in the SCCM, the largest international professional organization in the field. During the next decade, pharmacy services expanded to various ICU settings (both adult and pediatric), the operating room, and the emergency department. In these settings, pharmacists established clinical practices consisting of therapeutic drug monitoring, nutrition support, and participation in patient care rounds. Pharmacists also developed efficient and safe drug delivery systems with the evolution of critical care pharmacy satellites and other innovative programs. In the 1980s, critical care pharmacists designed specialized training programs and increased participation in critical care organizations. The number of critical care residencies and fellowships doubled between the early 1980s and the late 1990s. Standards for critical care residency were developed, and directories of residencies and fellowships were published. In 1989, the Clinical Pharmacy and Pharmacology Section was formed within the Society of Critical Care Medicine, the largest international, multidisciplinary, multispecialty critical care organization. This recognition acknowledged that pharmacists are necessary and valuable members of the physician-led multidisciplinary team. The Society of Critical Care Medicine Guidelines for Critical Care Services and Personnel deem that pharmacists are essential for the delivery of quality care to critically ill patients. These guidelines recommend that a pharmacist monitor drug regimen for dosing, adverse reactions, drug-drug interactions, and cost optimization for all hospitals providing critical care services. The guidelines also advocate that a specialized, decentralized pharmacist provide expertise in nutrition support, cardiorespiratory resuscitation, and clinical research in academic medical centers providing comprehensive critical care.
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Affiliation(s)
- A K Mohiuddin
- Department of Pharmacy, World University of Bangladesh, Bangladesh
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22
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Allegaert K, Simons S, Van Den Anker J. Research on medication use in the neonatal intensive care unit. Expert Rev Clin Pharmacol 2019; 12:343-353. [PMID: 30741041 DOI: 10.1080/17512433.2019.1580569] [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] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Research on medication use aims at assessing how much of current pharmacotherapy is rational. In neonates, this is hampered by extensive off-label drug use and limited knowledge. Areas covered: We report on medication use research and have conducted a systematic review of observational studies on medication use to provide an updated overview on characteristics, objectives, methods, and patterns in hospitalized neonates. Moreover, a review on aspects of medication use for opioids, anti-epileptics, gastric acid-related disorders and respiratory stimulants with emphasis on trends and impact of interventions is presented, illustrating how research on medication use can contribute to improved neonatal pharmacotherapy and more focused research. Medication use reports describe patterns and provide signals on irrational use, benchmarking, or can guide research priorities. Moreover, this may generate information on how neonatal health topics and their pharmacotherapy are handled over time or across regions. Expert opinion: Research on medicine utilization is relevant, since it will inform us on aspects like trends, variability, or about the impact and pattern of implementation of guidelines in neonates. Further progress necessitates to merge datasets on medication use with clinical characteristics, and perinatal drug use remains an area in need of additional research.
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Affiliation(s)
- Karel Allegaert
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Sinno Simons
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - John Van Den Anker
- c Division of Clinical Pharmacology, Department of Pediatrics , Children's National Health System , Washington , DC , USA.,d Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,e Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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23
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Costa HTMDL, Costa TX, Martins RR, Oliveira AG. Use of off-label and unlicensed medicines in neonatal intensive care. PLoS One 2018; 13:e0204427. [PMID: 30252920 PMCID: PMC6155521 DOI: 10.1371/journal.pone.0204427] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/09/2018] [Indexed: 01/18/2023] Open
Abstract
Purpose To evaluate the use of off-label and unlicensed medicines in a neonatal intensive care unit (NICU) of a teaching maternity hospital specialized in high risk pregnancy. Methods A prospective cohort study was conducted between August 2015 and July 2016. All newborns admitted to the NICU who had at least one medication prescribed and a hospital stay longer than 24 hours were included. The classification of off-label and unlicensed drugs for the neonatal population was done according to the information of Food and Drug Administration. Results A total of 17421 medication items were analyzed in 3935 prescriptions of 220 newborns. The proportion of newborns exposed to off-label drugs was 96.4%, and to unlicensed medicines was 66.8%. About one-half (49.3%) of the medication items were off-label and 24.6% were unlicensed. The main reason for off-label and unlicensed classification was, respectively, frequency of administration and the administration of adaptations of pharmaceutical forms. Conclusions Although there are actions to encourage the development of pharmacological studies with neonates, this study observed a high rate of prescription and exposure of newborns to off-label and unlicensed drugs in NICUs and pointed out areas of neonatal therapy that require scientific investment.
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Affiliation(s)
- Haline Tereza Matias de Lima Costa
- Integrated Multiprofessional Health Residency Program—Neonatal Intensive Care Unit, Pharmacy Department, Health Sciences Centre, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
- * E-mail:
| | - Tatiana Xavier Costa
- School Maternity Januário Cicco, Health Sciences Centre, Universidade Federal do Rio Grande Norte, Natal, RN, Brazil
| | - Rand Randall Martins
- Pharmacy Department, Health Sciences Centre, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Antônio Gouveia Oliveira
- Pharmacy Department, Health Sciences Centre, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
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24
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Rajaratnam S, Johnson C, Horne B, Bhatnagar R. Clinical News. Br J Hosp Med (Lond) 2018; 79:249-252. [PMID: 29727237 DOI: 10.12968/hmed.2018.79.5.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shantha Rajaratnam
- Professor, Deputy Head of School, Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Victoria, Australia
| | | | - Benjamin Horne
- Director of Cardiovascular and Genetic Epidemiology, Intermountain Medical Center Heart Institute, Salt Lake City, Utah
| | - Rahul Bhatnagar
- Clinical Lecturer in Respiratory Medicine, Academic Respiratory Unit, University of Bristol, Bristol
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25
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Flint RB, van Beek F, Andriessen P, Zimmermann LJ, Liem KD, Reiss IKM, de Groot R, Tibboel D, Burger DM, Simons SHP. Large differences in neonatal drug use between NICUs are common practice: time for consensus? Br J Clin Pharmacol 2018; 84:1313-1323. [PMID: 29624207 PMCID: PMC5980600 DOI: 10.1111/bcp.13563] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/24/2018] [Accepted: 02/11/2018] [Indexed: 01/27/2023] Open
Abstract
Aims Evidence for drug use in newborns is sparse, which may cause large differences in drug prescriptions. We aimed to investigate the differences between neonatal intensive care units (NICUs) in the Netherlands in currently prescribed drugs. Methods This multicentre study included neonates admitted during 12 months to four different NICUs. Drugs were classified in accordance with the Anatomical Therapeutic Chemical (ATC) classification system and assessed for on/off‐label status in relation to neonatal age. The treatment protocols for four common indications for drug use were compared: pain, intubation, convulsions and hypotension. Results A total of 1491 neonates (GA range 23+6–42+2 weeks) were included with a total of 32 182 patient days, 181 different drugs and 10 895 prescriptions of which 23% was off‐label in relation to neonatal age. Overall, anti‐infective drugs were most frequently used with a total of 3161 prescriptions, of which 4% was off‐label in relation to neonatal age. Nervous system drugs included 2500 prescriptions of which 31% was off‐label in relation to neonatal age. Nervous system drugs, blood and blood forming organs, and cardiovascular drugs showed the largest differences between NICUs with ranges of 919–2278, 554–1465, and 238–952 total prescriptions per 1000 patients per ATC class, respectively. Conclusions We showed that drug use varies widely in neonatal clinical practice. The drug classes with the highest proportion of off‐label drugs in relation to neonatal age showed the largest differences between NICUs, i.e. cardiovascular and nervous system drugs. Drug research in neonates should receive high priority to guarantee safe and appropriate medicines and optimal treatment.
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Affiliation(s)
- Robert B Flint
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Floor van Beek
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Peter Andriessen
- Department of Pediatrics, Division of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Luc J Zimmermann
- Department of Pediatrics, Maastricht University Medical Center, School of Oncology and Developmental Biology, School of Mental Health and Neuroscience, Maastricht, The Netherlands
| | - Kian D Liem
- Department of Pediatrics, Division of Neonatology, Radboudumc, Nijmegen, Nijmegen, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ronald de Groot
- Laboratory of Pediatric Infectious Diseases, Department of Pediatrics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Department of Pediatrics, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - David M Burger
- Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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