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Goyal N, Haribalakrishna A, Krishnamurthy B. A comparison of different dosing regimen of intravenous paracetamol for hemodynamically significant patent ductus arteriosus closure in premature neonates <32 weeks: a prospective observational study. J Perinatol 2024:10.1038/s41372-024-01966-8. [PMID: 38622217 DOI: 10.1038/s41372-024-01966-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/30/2024] [Accepted: 04/08/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE To compare the efficacy of low vs conventional dose intravenous paracetamol in early closure of haemodynamically significant patent ductus arteriosus within 7 days of life. METHODS Preterm infants (<32 weeks of gestation) having echocardiographic evidence of hsPDA were given low dose (15 mg/kg initially followed by 7.5 mg/kg every 6 hourly) vs conventional dose (15 mg/kg every 6 hourly) for 5-7 days. RESULTS In total, 56 infants (28 in each group) were enrolled. Ductal closure was achieved in 96% infants in the low-dose group and 100% infants in the conventional group (P = 1.00). Secondary outcomes, including ductal reopening and need for the second course of medical treatment (21% vs 3.5%, P = 0.1), median duration of hospital stay [30 (15, 43.5) vs 27 (18.5,45), P = 0.64], cumulative oxygen requirement [17.5 (7, 25) vs 14 (8.5, 25), P = 0.89], mortality (10.7% vs 25%, P = 0.29) and other morbidities, were comparable in both the groups. Median paracetamol levels were comparable in both the groups [53.4 μg/L (47, 2,70) vs 62.5 (55.6, 81.2), P = 0.67]. CONCLUSION Low-dose paracetamol was non-inferior to conventional dose paracetamol for early ductal closure in preterm infants.
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Affiliation(s)
- Nikita Goyal
- Department of Neonatology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Anitha Haribalakrishna
- Department of Neonatology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India.
| | - Bhaskar Krishnamurthy
- Department of Clinical Pharmacology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
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Watanabe H, Nagano N, Tsuji Y, Noto N, Ayusawa M, Morioka I. Challenges of pediatric pharmacotherapy: A narrative review of pharmacokinetics, pharmacodynamics, and pharmacogenetics. Eur J Clin Pharmacol 2024; 80:203-221. [PMID: 38078929 DOI: 10.1007/s00228-023-03598-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/20/2023] [Indexed: 02/07/2024]
Abstract
PURPOSE Personalized pharmacotherapy, including for the pediatric population, provides optimal treatment and has emerged as a major trend owing to advanced drug therapeutics and diversified drug selection. However, it is essential to understand the growth and developmental characteristics of this population to provide appropriate drug therapy. In recent years, clinical pharmacogenetics has accumulated knowledge in pediatric pharmacotherapy, and guidelines from professional organizations, such as the Clinical Pharmacogenetics Implementation Consortium, can be consulted to determine the efficacy of specific drugs and the risk of adverse effects. However, the existence of a large knowledge gap hinders the use of these findings in clinical practice. METHODS We provide a narrative review of the knowledge gaps in pharmacokinetics (PK) and pharmacodynamics (PD) in the pediatric population, focusing on the differences from the perspective of growth and developmental characteristics. In addition, we explored PK/PD in relation to pediatric clinical pharmacogenetics. RESULTS The lack of direct and indirect biomarkers for more accurate assessment of the effects of drug administration limits the current knowledge of PD. In addition, incorporating pharmacogenetic insights as pivotal covariates is indispensable in this comprehensive synthesis for precision therapy; therefore, we have provided recommendations regarding the current status and challenges of personalized pediatric pharmacotherapy. The integration of clinical pharmacogenetics with the health care system and institution of educational programs for health care providers is necessary for its safe and effective implementation. A comprehensive understanding of the physiological and genetic complexities of the pediatric population will facilitate the development of effective and personalized pharmacotherapeutic strategies.
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Affiliation(s)
- Hirofumi Watanabe
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Nobuhiko Nagano
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuhiro Tsuji
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Chiba, Japan
| | - Nobutaka Noto
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Mamoru Ayusawa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan
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3
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Cendejas-Hernandez J, Sarafian JT, Lawton VG, Palkar A, Anderson LG, Larivière V, Parker W. Paracetamol (acetaminophen) use in infants and children was never shown to be safe for neurodevelopment: a systematic review with citation tracking. Eur J Pediatr 2022; 181:1835-1857. [PMID: 35175416 PMCID: PMC9056471 DOI: 10.1007/s00431-022-04407-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/26/2022]
Abstract
Although widely believed by pediatricians and parents to be safe for use in infants and children when used as directed, increasing evidence indicates that early life exposure to paracetamol (acetaminophen) may cause long-term neurodevelopmental problems. Furthermore, recent studies in animal models demonstrate that cognitive development is exquisitely sensitive to paracetamol exposure during early development. In this study, evidence for the claim that paracetamol is safe was evaluated using a systematic literature search. Publications on PubMed between 1974 and 2017 that contained the keywords "infant" and either "paracetamol" or "acetaminophen" were considered. Of those initial 3096 papers, 218 were identified that made claims that paracetamol was safe for use with infants or children. From these 218, a total of 103 papers were identified as sources of authority for the safety claim. Conclusion: A total of 52 papers contained actual experiments designed to test safety, and had a median follow-up time of 48 h. None monitored neurodevelopment. Furthermore, no trial considered total exposure to drug since birth, eliminating the possibility that the effects of drug exposure on long-term neurodevelopment could be accurately assessed. On the other hand, abundant and sufficient evidence was found to conclude that paracetamol does not induce acute liver damage in babies or children when used as directed. What is Known: • Paracetamol (acetaminophen) is widely thought by pediatricians and parents to be safe when used as directed in the pediatric population, and is the most widely used drug in that population, with more than 90% of children exposed to the drug in some reports. • Paracetamol is known to cause liver damage in adults under conditions of oxidative stress or when used in excess, but increasing evidence from studies in humans and in laboratory animals indicates that the target organ for paracetamol toxicity during early development is the brain, not the liver. What is New: • This study finds hundreds of published reports in the medical literature asserting that paracetamol is safe when used as directed, providing a foundation for the widespread belief that the drug is safe. • This study shows that paracetamol was proven to be safe by approximately 50 short-term studies demonstrating the drug's safety for the pediatric liver, but the drug was never shown to be safe for neurodevelopment. Paracetamol is widely believed to be safe for infants and children when used as directed, despite mounting evidence in humans and in laboratory animals indicating that the drug is not safe for neurodevelopment. An exhaustive search of published work cited for safe use of paracetamol in the pediatric population revealed 52 experimental studies pointing toward safety, but the median follow-up time was only 48 h, and neurodevelopment was never assessed.
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Affiliation(s)
- Jasmine Cendejas-Hernandez
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
- WPLab, Inc, 1023 Wells St, Durham, NC 27707 USA
| | - Joshua T. Sarafian
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Victoria G. Lawton
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Antara Palkar
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Lauren G. Anderson
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Vincent Larivière
- École de Bibliothéconomie Et Des Sciences de L’information, Université de Montréal, Montreal, Canada
| | - William Parker
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
- WPLab, Inc, 1023 Wells St, Durham, NC 27707 USA
- Duke Global Health Institute, Duke University and Duke University Medical Center, Durham, NC 27710 USA
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Vanova J, Malinak D, Andrys R, Kubat M, Mikysek T, Rousarova E, Musilek K, Rousar T, Cesla P. Optimization of Gradient Reversed Phase High Performance Liquid Chromatography Analysis of Acetaminophen Oxidation Metabolites using Linear and Non-linear Retention Model. J Chromatogr A 2022; 1669:462956. [DOI: 10.1016/j.chroma.2022.462956] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 11/15/2022]
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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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6
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Olafuyi O, Abbasi MY, Allegaert K. Physiologically based pharmacokinetic modelling of acetaminophen in preterm neonates-The impact of metabolising enzyme ontogeny and reduced cardiac output. Biopharm Drug Dispos 2021; 42:401-417. [PMID: 34407204 DOI: 10.1002/bdd.2301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/14/2021] [Accepted: 07/19/2021] [Indexed: 12/20/2022]
Abstract
In preterm neonates, physiologically based pharmacokinetic (PBPK) models are suited for studying the effects of maturational and non-maturational factors on the pharmacokinetics of drugs with complex age-dependent metabolic pathways like acetaminophen (APAP). The aim of this study was to determine the impact of drug metabolising enzymes ontogeny on the pharmacokinetics of APAP in preterm neonates and to study the effect of reduced cardiac output (CO) on its PK using PBPK modelling. A PBPK model for APAP was first developed and validated in adults and then scaled to paediatric age groups to account for the effect of enzyme ontogeny. In preterm neonates, CO was reduced by 10%, 20%, and 30% to determine how this might affect APAP PK in preterm neonates. In all age groups, the predicted concentration-time profiles of APAP were within 5th and 95th percentile of the clinically observed concentration-time profiles and the predicted Cmax and AUC were within 2-folds of the reported parameters in clinical studies. Sulfation accounted for most of APAP metabolism in children, with the highest contribution of 68% in preterm neonates. A reduction in CO by up to 30% did not significantly alter the clearance of APAP in preterm neonates. The model successfully incorporated the ontogeny of drug metabolising enzymes involved in APAP metabolism and adequately predicted the PK of APAP in preterm neonates. A reduction in hepatic perfusion as a result of up to 30% reduction in CO has no effect on the PK of APAP in preterm neonates.
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Affiliation(s)
- Olusola Olafuyi
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | | | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Saini A, Maher KO, Deshpande SR. Nonopioid analgesics for perioperative and cardiac surgery pain in children: Current evidence and knowledge gaps. Ann Pediatr Cardiol 2019; 13:46-55. [PMID: 32030035 PMCID: PMC6979012 DOI: 10.4103/apc.apc_190_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/05/2019] [Accepted: 10/08/2019] [Indexed: 11/23/2022] Open
Abstract
Objective: The purpose of this review is to present the available literature on the use of nonopioid analgesics such as nonsteroidal anti-inflammatory drugs in postcardiac surgery pediatric patients, mainly to focus on patients <1 year of age, and to provide the foundation for future research. Materials and Methods: Published studies that address the use on nonopioid medications for postoperative sedation and analgesia in infants and children undergoing cardiac surgery were identified from online sources. Studies were reviewed by two authors independently to assess the quality of the data as well as the evidence. Due to limited availability of such studies, the review was then expanded to include use in noncardiac procedures as well as to expanded age groups. All studies that met the primary objective were included. Results/Data Synthesis: Majority of the studies in the population of interest were related to use of ketorolac. Five studies specifically addressed ketorolac use in cardiac patients. In addition, studies were reviewed for nonopioid analgesia in noncardiac patients and included as a part of the available evidence as in the case of acetaminophen use. Newer agents as well as agents with very limited information were also acknowledged. Conclusion: Nonopioid medications appear to show promise for analgesia in infants undergoing cardiac surgery, with ketorolac being the most potent agent as a potential substitute for opioids. These agents demonstrate a reasonable safety profile even in the very young. There continue to be significant gaps in knowledge before their adoption becomes routine. However, gives the awareness regarding short-term and long-term impact of opioid use in this vulnerable population, and studies of such agents are an urgent need.
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Affiliation(s)
- Ashish Saini
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kevin O Maher
- Division of Pediatric Cardiology, Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Shriprasad R Deshpande
- Heart Transplant and Advanced Cardiac Therapies Program, Children's National Health Institute, Washington, DC, USA
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Polymorphic Expression of UGT1A9 is Associated with Variable Acetaminophen Glucuronidation in Neonates: A Population Pharmacokinetic and Pharmacogenetic Study. Clin Pharmacokinet 2019; 57:1325-1336. [PMID: 29654492 DOI: 10.1007/s40262-018-0634-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Acetaminophen (paracetamol, APAP) is widely used as an analgesic and antipyretic drug in children and neonates. A number of enzymes contribute to the metabolism of acetaminophen, and genetic factors might be important to explain variability in acetaminophen metabolism among individuals. METHODS The current investigation utilized a previously published parent-metabolite population pharmacokinetic model describing acetaminophen glucuronidation, sulfation, and oxidation to examine the potential role of genetic variability on the relevant metabolic pathways. Neonates were administered 30-min intravenous infusions of acetaminophen 15 mg/kg every 12 h (< 28 weeks' gestational age [GA]) or every 8 h (≥ 28 weeks GA) for 48 h. A total of 18 sequence variations (SVs) in UDP-glucuronosyltransferase (UGT), sulfotransferase (SULT), and cytochrome P450 (CYP) genes from 33 neonates (aged 1-26 days) were examined in a stepwise manner for an effect on the metabolic formation clearance of acetaminophen by glucuronidation (UGT), sulfation (SULT), and oxidation (CYP). The stepwise covariate modeling procedure was performed using NONMEM® version 7.3. RESULTS Incorporation of genotype as a covariate for one SV located in the UGT1A9 gene promoter region (rs3832043, - 118 > insT, T9 > T10) significantly improved model fit (likelihood ratio test, p < 0.001) and reduced between-subject variability in glucuronide formation clearance. Individuals with the UGT1A9 T10 polymorphism, indicating insertion of an additional thymidine nucleotide, had a 42% reduction in clearance to APAP-glucuronide as compared to their wild-type counterparts. CONCLUSION This study shows a pharmacogenetic effect of an SV in the UGT1A9 promoter region on the metabolism of acetaminophen in neonates.
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van den Anker J, Reed MD, Allegaert K, Kearns GL. Developmental Changes in Pharmacokinetics and Pharmacodynamics. J Clin Pharmacol 2018; 58 Suppl 10:S10-S25. [DOI: 10.1002/jcph.1284] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 06/21/2018] [Indexed: 12/22/2022]
Affiliation(s)
- John van den Anker
- Division of Clinical Pharmacology; Children's National Health System; Washington DC USA
- Division of Paediatric Pharmacology and Pharmacometrics; University of Basel Children's Hospital; Basel Switzerland
- Intensive Care and Department of Pediatric Surgery; Erasmus Medical Center-Sophia Children's Hospital; Rotterdam the Netherlands
| | - Michael D. Reed
- Emeritus Professor of Pediatrics; School of Medicine; Case Western Reserve University; Cleveland OH USA
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery; Erasmus Medical Center-Sophia Children's Hospital; Rotterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Erasmus Medical Center-Sophia Children's Hospital; Rotterdam the Netherlands
- Department of Development and Regeneration; KU Leuven; Leuven Belgium
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Mooij MG, van Duijn E, Knibbe CAJ, Allegaert K, Windhorst AD, van Rosmalen J, Hendrikse NH, Tibboel D, Vaes WHJ, de Wildt SN. Successful Use of [ 14C]Paracetamol Microdosing to Elucidate Developmental Changes in Drug Metabolism. Clin Pharmacokinet 2018; 56:1185-1195. [PMID: 28155137 PMCID: PMC5591809 DOI: 10.1007/s40262-017-0508-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background We previously showed the practical and ethical feasibility of using [14C]-microdosing for pharmacokinetic studies in children. We now aimed to show that this approach can be used to elucidate developmental changes in drug metabolism, more specifically, glucuronidation and sulfation, using [14C]paracetamol (AAP). Methods Infants admitted to the intensive care unit received a single oral [14C]AAP microdose while receiving intravenous therapeutic AAP every 6 h. [14C]AAP pharmacokinetic parameters were estimated. [14C]AAP and metabolites were measured with accelerator mass spectrometry. The plasma area under the concentration-time curve from time zero to infinity and urinary recovery ratios were related to age as surrogate markers of metabolism. Results Fifty children [median age 6 months (range 3 days–6.9 years)] received a microdose (3.3 [2.0–3.5] ng/kg; 64 [41–71] Bq/kg). Plasma [14C]AAP apparent total clearance was 0.4 (0.1–2.6) L/h/kg, apparent volume of distribution was 1.7 (0.9–8.2) L/kg, and the half-life was 2.8 (1–7) h. With increasing age, plasma and urinary AAP-glu/AAP and AAP-glu/AAP-sul ratios significantly increased by four fold, while the AAP-sul/AAP ratio significantly decreased. Conclusion Using [14C]labeled microdosing, the effect of age on orally administered AAP metabolism was successfully elucidated in both plasma and urine. With minimal burden and risk, microdosing is attractive to study developmental changes in drug disposition in children.
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Affiliation(s)
- Miriam G Mooij
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Catherijne A J Knibbe
- Division of Pharmacology, Faculty of Science, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Louvain, Belgium
| | - Albert D Windhorst
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | | | - N Harry Hendrikse
- Department of Pharmacy and Clinical Pharmacology, VU University Medical Center, Amsterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
- Department of Pharmacology and Toxicology, Radboud University, PO box 9101, Geert Grooteplein 21, Nijmegen, 6500 HB, The Netherlands.
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Choi SJ, Moon S, Choi UY, Chun YH, Lee JH, Rhim JW, Lee J, Kim HM, Jeong DC. The antipyretic efficacy and safety of propacetamol compared with dexibuprofen in febrile children: a multicenter, randomized, double-blind, comparative, phase 3 clinical trial. BMC Pediatr 2018; 18:201. [PMID: 29935535 PMCID: PMC6015655 DOI: 10.1186/s12887-018-1166-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 06/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to compare the antipyretic efficacy, safety, and tolerability between oral dexibuprofen and intravenous propacetamol in children with upper respiratory tract infection (URTI) presenting with fever. METHODS Patients aging from 6 months to 14 years admitted for URTI with axillary body temperature ≥ 38.0 °C were enrolled and randomized into the study or control group. Patients in the study group were intravenously infused with propacetamol and subsequently oral placebo medication was administered. Patients in the control group were intravenously infused with 100 mL of 0.9% sodium chloride solution without propacetamol and then oral dexibuprofen was administered. We checked the body temperature of all patients at 0.5 h (hr), 1 h, 1.5 h, 2 h, 3 h, 4 h, and 6 h after oral placebo or dexibuprofen had been applied. RESULTS A total of 263 patients (125 in the study group) were finally enrolled. The body temperatures of patients in the study group were significantly lower until 2 h after administration (37.73 ± 0.58 vs 38.36 ± 0.69 °C (p < 0.001), 37.37 ± 0.53 vs 37.88 ± 0.69 °C (p < 0.001), 37.27 ± 0.60 vs 37.62 ± 0.66 °C (p < 0.001), 37.25 ± 0.62 vs 37.40 ± 0.60 °C (p = 0.0452), at 0.5 h, 1 h, 1.5 h, and 2 h, respectively). The two groups showed no significant differences in terms of the range of body temperature decrease, the Area Under the Curve of body temperature change for antipyretic administration-and-time relationship, the maximum value of body temperature decrease during the 6 h test period, the number of patients whose body temperature normalized (< 37.0 °C), the mean time when first normalization of body temperature, and the development of adverse events including gastrointestinal problem, elevated liver enzyme, and thrombocytopenia. CONCLUSIONS Intravenous propacetamol may be a safe and effective choice for pediatric URTI patients presenting with fever who are not able to take oral medications or need faster fever control. TRIAL REGISTRATION CRIS KCT0002888 . Date of registration: July 31st, 2013.
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Affiliation(s)
- Seung Jun Choi
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Graduate School of Medicine, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Sena Moon
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, 222, Banpodaero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Ui Yoon Choi
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, 222, Banpodaero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Yoon Hong Chun
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, 222, Banpodaero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jung Hyun Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, 222, Banpodaero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jung Woo Rhim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, 222, Banpodaero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jin Lee
- Department of Pediatrics, Hanjin General Hospital, Seoul, Republic of Korea
| | - Hwang Min Kim
- Department of Pediatrics, Yonsei Christian Hospital, Wonju, Republic of Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, 222, Banpodaero, Seocho-gu, Seoul, 06591, Republic of Korea. .,Vaccine Bio-research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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12
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Aranda JV, Salomone F, Valencia GB, Beharry KD. Non-steroidal Anti-inflammatory Drugs in Newborns and Infants. Pediatr Clin North Am 2017; 64:1327-1340. [PMID: 29173788 DOI: 10.1016/j.pcl.2017.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen are used in young infants and newborns for pain and fever control, patent ductus closure, prevention of intraventricular hemorrhage, and potentially for prevention of retinopathy of prematurity. These drugs inhibit cyclooxygenase 1 (COX-1), COX-2, and peroxidases, thus, blocking prostaglandin (PG) synthesis. PGs are eicosanoids that regulate several physiologic, pathologic, and cellular processes, including vasomotor tone, platelet aggregation, sensitization of neurons to pain, and many molecular events critical to physiologic homeostasis. NSAIDs inhibit caspases and cell death. Increasing knowledge of these molecular entities may allow targeted drug development to prevent or minimize neonatal morbidities.
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Affiliation(s)
- Jacob V Aranda
- State University of New York Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY 11203, USA.
| | - Fabrizio Salomone
- Neonatology and Pulmonary Rare Disease Unit, Corporate Pre-Clinical R and D, Chiesi Farmaceutici S.p.A, Largo Belloli 11/A, Parma IT-43122, Italy
| | - Gloria B Valencia
- State University of New York Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY 11203, USA
| | - Kay D Beharry
- State University of New York Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY 11203, USA
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Martin LD, Jimenez N, Lynn AM. A review of perioperative anesthesia and analgesia for infants: updates and trends to watch. F1000Res 2017; 6:120. [PMID: 28232869 PMCID: PMC5302152 DOI: 10.12688/f1000research.10272.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2017] [Indexed: 01/13/2023] Open
Abstract
This review focuses on pharmacokinetics and pharmacodynamics of opioid and non-opioid analgesics in neonates and infants. The unique physiology of this population differs from that of adults and impacts drug handling. Morphine and remifentanil are described as examples of older versus recently developed opiates to compare and contrast pharmacokinetics and pharmacodynamics in infants. Exploration of genetics affecting both pharmacokinetics and pharmacodynamics of opiates is an area of active research, as is the investigation of a new class of mu-opiate-binding agents which seem selective for analgesic pathways while having less activity in pathways linked to side effects. The kinetics of acetaminophen and of ketorolac as examples of parenteral non-steroidal analgesics in infants are also discussed. The growth in regional anesthesia for peri-operative analgesia in infants can fill an important role minimizing intra-operative anesthetic exposure to opioids and transitioning to post-operative care. Use of multi-modal techniques is recommended to decrease undesirable opiate-related side effects in this vulnerable population.
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Affiliation(s)
- Lizabeth D Martin
- University of Washington School of Medicine, Department of Anesthesiology & Pain Medicine, Seattle Children’s Hospital, Seattle, WA, USA
| | - Nathalia Jimenez
- University of Washington School of Medicine, Department of Anesthesiology & Pain Medicine, Seattle Children’s Hospital, Seattle, WA, USA
| | - Anne M Lynn
- University of Washington School of Medicine, Department of Anesthesiology & Pain Medicine, Seattle Children’s Hospital, Seattle, WA, USA
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Developmental pharmacokinetics and pharmacodynamics of parenteral opioids and nonsteroidal anti-nflammatory drugs in neonates and infants☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201701000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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15
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Martin L, Jimenez N, Lynn AM. Developmental pharmacokinetics and pharmacodynamics of parenteral opioids and nonsteroidal anti-nflammatory drugs in neonates and infants. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2016.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Martin L, Jimenez N, Lynn AM. Farmacología del desarrollo de analgésicos opioides y no esteroideos en neonatos e infantes. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2016.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Baarslag MA, Allegaert K, Van Den Anker JN, Knibbe CAJ, Van Dijk M, Simons SHP, Tibboel D. Paracetamol and morphine for infant and neonatal pain; still a long way to go? Expert Rev Clin Pharmacol 2016; 10:111-126. [PMID: 27785937 DOI: 10.1080/17512433.2017.1254040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pharmacologic pain management in newborns and infants is often based on limited scientific data. To close the knowledge gap, drug-related research in this population is increasingly supported by the authorities, but remains very challenging. This review summarizes the challenges of analgesic studies in newborns and infants on morphine and paracetamol (acetaminophen). Areas covered: Aspects such as the definition and multimodal character of pain are reflected to newborn infants. Specific problems addressed include defining pharmacodynamic endpoints, performing clinical trials in this population and assessing developmental changes in both pharmacokinetics and pharmacodynamics. Expert commentary: Neonatal and infant pain management research faces two major challenges: lack of clear biomarkers and very heterogeneous pharmacokinetics and pharmacodynamics of analgesics. There is a clear call for integral research addressing the multimodality of pain in this population and further developing population pharmacokinetic models towards physiology-based models.
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Affiliation(s)
- Manuel A Baarslag
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Karel Allegaert
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,b Department of development and regeneration , KU Leuven , Leuven , Belgium
| | - John N Van Den Anker
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,c Division of Clinical Pharmacology , Children's National Health System , Washington , DC , USA.,d Division of Pediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Catherijne A J Knibbe
- e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands.,f Division of Pharmacology, Leiden Academic Center for Drug Research , Leiden University , Leiden , the Netherlands
| | - Monique Van Dijk
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Sinno H P Simons
- g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Dick Tibboel
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
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Neonatal pain management: still in search for the Holy Grail. Int J Clin Pharmacol Ther 2016; 54:514-23. [PMID: 27087155 PMCID: PMC5012190 DOI: 10.5414/cp202561] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 12/31/2022] Open
Abstract
Inadequate pain management but also inappropriate use of analgesics in early infancy has negative effects on neurodevelopmental outcome. As a consequence, neonatal pain management is still in search for the Holy Grail. At best, effective pain management is based on prevention, assessment, and treatment followed by a re-assessment of the pain to determine if additional treatment is still necessary. Unfortunately, epidemiological observations suggest that neonates are undergoing painful procedures very frequently, unveiling the need for effective preventive, non-pharmacological strategies. In addition, assessment is still based on validated, multimodal, but subjective pain assessment tools. Finally, in neonatal intensive care units, there is a shift in clinical practices (e.g., shorter intubation and ventilation), and this necessitates the development and validation of new pharmacological treatment modalities. To illustrate this, a shift in the use of opioids to paracetamol has occurred and short-acting agents (remifentanil, propofol) are more commonly administered to neonates. In addition to these new modalities and as part of a more advanced approach of the developmental pharmacology of analgesics, pharmacogenetics also emerged as a tool for precision medicine in neonates. To assure further improvement of neonatal pain management the integration of pharmacogenetics with the usual covariates like weight, age and/or disease characteristics is needed.
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Cook SF, Roberts JK, Samiee-Zafarghandy S, Stockmann C, King AD, Deutsch N, Williams EF, Allegaert K, Wilkins DG, Sherwin CMT, van den Anker JN. Population Pharmacokinetics of Intravenous Paracetamol (Acetaminophen) in Preterm and Term Neonates: Model Development and External Evaluation. Clin Pharmacokinet 2016; 55:107-19. [PMID: 26201306 PMCID: PMC5564323 DOI: 10.1007/s40262-015-0301-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of this study were to develop a population pharmacokinetic model for intravenous paracetamol in preterm and term neonates and to assess the generalizability of the model by testing its predictive performance in an external dataset. METHODS Nonlinear mixed-effects models were constructed from paracetamol concentration-time data in NONMEM 7.2. Potential covariates included body weight, gestational age, postnatal age, postmenstrual age, sex, race, total bilirubin, and estimated glomerular filtration rate. An external dataset was used to test the predictive performance of the model through calculation of bias, precision, and normalized prediction distribution errors. RESULTS The model-building dataset included 260 observations from 35 neonates with a mean gestational age of 33.6 weeks [standard deviation (SD) 6.6]. Data were well-described by a one-compartment model with first-order elimination. Weight predicted paracetamol clearance and volume of distribution, which were estimated as 0.348 L/h (5.5 % relative standard error; 30.8 % coefficient of variation) and 2.46 L (3.5 % relative standard error; 14.3 % coefficient of variation), respectively, at the mean subject weight of 2.30 kg. An external evaluation was performed on an independent dataset that included 436 observations from 60 neonates with a mean gestational age of 35.6 weeks (SD 4.3). The median prediction error was 10.1 % [95 % confidence interval (CI) 6.1-14.3] and the median absolute prediction error was 25.3 % (95 % CI 23.1-28.1). CONCLUSIONS Weight predicted intravenous paracetamol pharmacokinetics in neonates ranging from extreme preterm to full-term gestational status. External evaluation suggested that these findings should be generalizable to other similar patient populations.
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Affiliation(s)
- Sarah F Cook
- Center for Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Jessica K Roberts
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Samira Samiee-Zafarghandy
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Chris Stockmann
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Amber D King
- Center for Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Nina Deutsch
- Division of Anesthesiology, Sedation, and Perioperative Medicine, Children's National Health System, Washington, DC, USA
| | - Elaine F Williams
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Karel Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Diana G Wilkins
- Center for Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
- Division of Medical Laboratory Sciences, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Departments of Pediatrics, Integrative Systems Biology, Pharmacology and Physiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
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20
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Härmä A, Aikio O, Hallman M, Saarela T. Intravenous Paracetamol Decreases Requirements of Morphine in Very Preterm Infants. J Pediatr 2016; 168:36-40. [PMID: 26323200 DOI: 10.1016/j.jpeds.2015.08.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/29/2015] [Accepted: 08/03/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether intravenous paracetamol therapy is effective in pain therapy in premature infants. STUDY DESIGN From June 2009 to December 2011, 108 infants born very low gestational age (<32 weeks) (VLGA) were given intravenous paracetamol before the age of 72 hours. The loading dose was 20 mg/kg followed by 7.5 mg/kg every 6 hours. One hundred ten VLGA infants admitted from October 2007 to May 2009 formed the comparison group who received no paracetamol. Intravenous morphine was exclusively used as the opiate. Morphine dosage was calculated as the cumulative dose administered during the neonatal intensive care unit period. Pain symptoms were screened using pain scale scoring Neonatal Infant Acute Pain Assessment Scale. The number of apneas during the neonatal intensive care unit stay, and ventilation days per patient, were calculated. RESULTS The mean (SD) total number of paracetamol doses per patient was 16.9 (11.7), and the postnatal age for the first dose was 13.3 (13.8) hours. Infants in the paracetamol group needed significantly fewer morphine doses per patient than the comparisons, 1.78 (4.56) doses vs 4.35 (11.53), P = .044. The exposed had lower cumulative morphine dosage 0.17 (0.45) mg/kg vs 0.37 (0.96) mg/kg, P = .047. There were no differences in the Neonatal Infant Acute Pain Assessment Scale scores, or the numbers of apneas, or ventilation days. There was no evidence of adverse events including hepatic toxicity. CONCLUSION The need for morphine decreased significantly after the introduction of paracetamol for the VLGA infants.
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Affiliation(s)
- Antti Härmä
- PEDEGO Research Unit, and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Outi Aikio
- PEDEGO Research Unit, and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.
| | - Mikko Hallman
- PEDEGO Research Unit, and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Timo Saarela
- PEDEGO Research Unit, and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
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Kabataş EU, Dursun A, Beken S, Dilli D, Zenciroğlu A, Okumuş N. Efficacy of Single Dose Oral Paracetamol in Reducing Pain During Examination for Retinopathy of Prematurity: A Blinded Randomized Controlled Trial. Indian J Pediatr 2016; 83:22-6. [PMID: 25947264 DOI: 10.1007/s12098-015-1765-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 04/02/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the efficacy of paracetamol in reducing pain during examination for retinopathy of prematurity (ROP) in preterm infants. METHODS A total of 114 infants undergoing eye examination for retinopathy of prematurity screening were prospectively randomized. Topical anesthetic (Proparacaine; Alcaine® drop 0.5%) was applied 30 s before the eye examination in all the infants. The infants in the intervention group (Group 1, n = 58) received 15 mg/kg of oral paracetamol, 60 min before the examination. The control group (Group 2, n = 56) received the same volume of sterile water per oral with an opaque syringe. Primary outcome measurement was pain assessed by Premature Infant Pain Profile (PIPP) score. Secondary outcome measurements were tachycardia (>180 bpm)/bradycardia (<100 bpm), desaturations (<85% for >10 s), and crying time. RESULTS The groups were similar for gestational age, birthweight or postnatal age at examination. The intervention group had a significantly lower mean PIPP score during eye examination, following insertion of the speculum [Group 1:12 (9-13) vs. Group 2:14 (13-15), p 0.001]. There were no significant differences between the groups with regard to crying time and the number of the patients with tachycardia/bradycardia and desaturation. CONCLUSIONS Oral paracetamol modestly reduces pain scores during eye examinations. Further cross-over trials on dose and frequency of paracetamol and combination of pharmacological with non-pharmacological approaches and paracetamol alone as a single agent in significant pain reduction are needed.
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Affiliation(s)
- Emrah Utku Kabataş
- Pediatric Ophtalmology Unit, Department of Ophtalmology, Dr. Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Arzu Dursun
- Neonatal Intensive Care Unit, Department of Neonatology, Dr. Sami Ulus Maternity and Children Research and Training Hospital, 06080, Ankara, Turkey
| | - Serdar Beken
- Neonatal Intensive Care Unit, Department of Neonatology, Dr. Sami Ulus Maternity and Children Research and Training Hospital, 06080, Ankara, Turkey
| | - Dilek Dilli
- Neonatal Intensive Care Unit, Department of Neonatology, Dr. Sami Ulus Maternity and Children Research and Training Hospital, 06080, Ankara, Turkey.
| | - Ayşegül Zenciroğlu
- Neonatal Intensive Care Unit, Department of Neonatology, Dr. Sami Ulus Maternity and Children Research and Training Hospital, 06080, Ankara, Turkey
| | - Nurullah Okumuş
- Neonatal Intensive Care Unit, Department of Neonatology, Dr. Sami Ulus Maternity and Children Research and Training Hospital, 06080, Ankara, Turkey
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Pacifici GM, Allegaert K. Clinical pharmacology of paracetamol in neonates: a review. CURRENT THERAPEUTIC RESEARCH 2015; 77:24-30. [PMID: 25709719 PMCID: PMC4329422 DOI: 10.1016/j.curtheres.2014.12.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/03/2014] [Indexed: 11/22/2022]
Abstract
Paracetamol is commonly used to control mild-to-moderate pain or to reduce opioid exposure as part of multimodal analgesia, and is the only compound recommended to treat fever in neonates. Paracetamol clearance is lower in neonates than in children and adults. After metabolic conversion, paracetamol is subsequently eliminated by the renal route. The main metabolic conversions are conjugation with glucuronic acid and with sulphate. In the urine of neonates sulphated paracetamol concentration is higher than the glucuronidated paracetamol level, suggesting that sulfation prevails over glucuronidation in neonates. A loading dose of 20 mg/kg followed by 10 mg/kg every 6 hours of intravenous paracetamol is suggested to achieve a compartment concentration of 11 mg/L in late preterm and term neonates. Aiming for the same target concentration, oral doses are similar with rectal administration of 25 to 30 mg/kg/d in preterm neonates of 30 weeks' gestation, 45 mg/kg/d in preterm infants of 34 weeks' gestation, and 60 mg/kg/d in term neonates are suggested. The above-mentioned paracetamol doses for these indications (pain, fever) are well tolerated in neonates, but do not result in a significant increase in liver enzymes, and do not affect blood pressure and have limited effects on heart rate. In contrast, the higher doses suggested in extreme preterm neonates to induce closure of the patent ductus arteriosus have not yet been sufficiently evaluated regarding efficacy or safety. Moreover, focussed pharmacovigilance to explore the potential causal association between paracetamol exposure during perinatal life and infancy and subsequent atopy is warranted.
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Affiliation(s)
- Gian Maria Pacifici
- Translational Department and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Karel Allegaert
- Neonatal Intensive Care Unit, Division of Woman and Child, University Hospitals Leuven, Leuven, Belgium
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Intravenous paracetamol with a lower dose is also effective for the treatment of patent ductus arteriosus in pre-term infants. Cardiol Young 2015; 25:1060-4. [PMID: 25160728 DOI: 10.1017/s1047951114001577] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Haemodynamically significant patent ductus arteriosus is a significant cause of morbidity and mortality in pre-term infants. This retrospective study was conducted to investigate the usefulness of lower-dose paracetamol for the treatment of patent ductus arteriosus in pre-term infants. MATERIALS AND METHODS A total of 13 pre-term infants who received intravenous paracetamol because of contrindications or side effects to oral ibuprofen were retrospectively enrolled. In the first patient, the dose regimen was 15 mg/kg/dose, every 6 hours. As the patient developed significant elevation in transaminase levels, the dose was decreased to 10 mg/kg/dose, every 8 hours in the following 12 patients. Echocardiographic examination was conducted daily. In case of closure, it was repeated after 2 days and when needed thereafter in terms of reopening. RESULTS A total of 13 patients received intravenous paracetamol. Median gestational age was 29 weeks ranging from 24 to 31 weeks and birth weight was 950 g ranging from 470 to 1390 g. The median postnatal age at the first intravenous paracetamol dose was 3 days ranging from 2 to 9 days. In 10 of the 13 patients (76.9%), patent ductus arteriosus was closed at the median 2nd day of intravenous paracetamol ranging from 1 to 4 days. When the patient who developed hepatotoxicity was eliminated, the closure rate was found to be 83.3% (10/12). CONCLUSION Intravenous paracetamol may be a useful treatment option for the treatment of patent ductus arteriosus in pre-term infants with contrindication to ibuprofen. In our experience, lower-dose paracetamol is effective in closing the patent ductus arteriosus in 83.3% of the cases.
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Krekels EHJ, van Ham S, Allegaert K, de Hoon J, Tibboel D, Danhof M, Knibbe CAJ. Developmental changes rather than repeated administration drive paracetamol glucuronidation in neonates and infants. Eur J Clin Pharmacol 2015; 71:1075-82. [PMID: 26139379 PMCID: PMC4532713 DOI: 10.1007/s00228-015-1887-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/09/2015] [Indexed: 01/02/2023]
Abstract
Purpose Based on recovered metabolite ratios in urine, it has been concluded that paracetamol glucuronidation may be up-regulated upon multiple dosing. This study investigates paracetamol clearance in neonates and infants after single and multiple dosing using a population modelling approach. Methods A population pharmacokinetic model was developed in NONMEM VI, based on paracetamol plasma concentrations from 54 preterm and term neonates and infants, and on paracetamol, paracetamol-glucuronide and paracetamol-sulphate amounts in urine from 22 of these patients. Patients received either a single intravenous propacetamol dose or up to 12 repeated doses. Results Paracetamol and metabolite disposition was best described with one-compartment models. The formation clearance of paracetamol-sulphate was 1.46 mL/min/kg1.4, which was about 5.5 times higher than the formation clearance of the glucuronide of 0.266 mL/min/kg. The renal excretion rate constants of both metabolites was estimated to be 11.4 times higher than the excretion rate constant of unchanged paracetamol, yielding values of 0.580 mL/min/kg. Developmental changes were best described by bodyweight in linear relationships on the distribution volumes, the formation of paracetamol-glucuronide and the unchanged excretion of paracetamol, and in an exponential relationship on the formation of paracetamol-sulphate. There was no evidence for up-regulation or other time-varying changes in any of the model parameters. Simulations with this model illustrate how paracetamol-glucuronide recovery in urine increases over time due to the slower formation of this metabolite and in the absence of up-regulation. Conclusions Developmental changes, described by bodyweight-based functions, rather than up-regulation, explain developmental changes in paracetamol disposition in neonates and infants. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1887-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elke H J Krekels
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden, The Netherlands
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van Ganzewinkel C, Derijks L, Anand KJS, van Lingen RA, Neef C, Kramer BW, Andriessen P. Multiple intravenous doses of paracetamol result in a predictable pharmacokinetic profile in very preterm infants. Acta Paediatr 2014; 103:612-7. [PMID: 24654967 DOI: 10.1111/apa.12638] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 02/20/2014] [Accepted: 03/17/2014] [Indexed: 11/30/2022]
Abstract
AIM The therapeutic options available to treat neonatal pain are limited, and one alternative for nonopioid systemic treatment is paracetamol. However, pharmacokinetic data from prolonged administration of intravenous paracetamol in neonates are limited. The aim of this study was to present pharmacokinetics after multiple dose of intravenous paracetamol in very preterm infants of <32 weeks' gestation. METHODS Fifteen very preterm infants received five, six-hourly doses of intravenous paracetamol (7.5 mg/kg). Blood samples were taken to measure paracetamol, glutathione and hepatic function, together with urine samples for paracetamol metabolites. RESULTS A two-compartment pharmacokinetic model gave the best fit for all individual patients and resulted in a predictable pharmacokinetic profile. The estimated pharmacokinetic population parameters were volume of distribution 0.764 ± 0.225 L/kg, elimination rate constant (ke ) 0.117 ± 0.091/h and intercompartment rate constants k12 0.607 ± 0.734/h and k21 1.105 ± 0.762/h. CONCLUSION Our study found that multiple doses of intravenous paracetamol resulted in a predictable pharmacokinetic profile in very preterm infants. Increases in postmenstrual age and weight were associated with increased clearance. No evidence of hepatotoxicity was found.
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Affiliation(s)
- C van Ganzewinkel
- Division of Neonatology; Department of Pediatrics; Máxima Medical Centre; Veldhoven The Netherlands
| | - L Derijks
- Department of Clinical Pharmacy; Máxima Medical Centre; Veldhoven The Netherlands
| | - KJS Anand
- University of Tennessee Health Science Center; Le Bonheur Children's Hospital; Memphis TN USA
| | - RA van Lingen
- Division of Neonatology; Princess Amalia Department of Pediatrics; Isala Clinics; Zwolle The Netherlands
| | - C Neef
- Department of Clinical Pharmacy & Toxicology; Maastricht University Medical Centre; CAPHRI School for Public Health and Primary Care; Maastricht The Netherlands
| | - BW Kramer
- Department of Pediatrics; Maastricht University Medical Centre; Maastricht The Netherlands
- School of Mental Health and Neuroscience; Maastricht University; Maastricht The Netherlands
- School of Oncology and Developmental Biology; Maastricht University; Maastricht The Netherlands
| | - P Andriessen
- Division of Neonatology; Department of Pediatrics; Máxima Medical Centre; Veldhoven The Netherlands
- Faculty of Health, Medicine and Life Science; Maastricht University; Maastricht The Netherlands
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Owens KH, Murphy PGM, Medlicott NJ, Kennedy J, Zacharias M, Curran N, Sreebhavan S, Thompson-Fawcett M, Reith DM. Population pharmacokinetics of intravenous acetaminophen and its metabolites in major surgical patients. J Pharmacokinet Pharmacodyn 2014; 41:211-21. [DOI: 10.1007/s10928-014-9358-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 04/09/2014] [Indexed: 01/13/2023]
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Wang C, Allegaert K, Tibboel D, Danhof M, van der Marel CD, Mathot RAA, Knibbe CAJ. Population pharmacokinetics of paracetamol across the human age-range from (pre)term neonates, infants, children to adults. J Clin Pharmacol 2014; 54:619-29. [PMID: 24375166 DOI: 10.1002/jcph.259] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 12/26/2013] [Indexed: 11/11/2022]
Abstract
In order to characterize the variation in pharmacokinetics of paracetamol across the human age span, we performed a population pharmacokinetic analysis from preterm neonates to adults with specific focus on clearance. Concentration-time data obtained in 220 neonates (post-natal age 1-76 days, gestational age 27-42 weeks), infants (0.11-1.33 yrs), children (2-7 yrs) and adults (19-34 yrs) were analyzed using NONMEM 7.2. In the covariate analysis, linear functions, power functions, and a power function with a bodyweight-dependent exponent were tested. Between preterm neonates and adults, linear bodyweight functions were identified for Q2, Q3, V1, V2, and V3, while for CL a power function with a bodyweight-dependent exponent k was identified (CLi = CLp × (BW/70)(k) ). The exponent k was found to decrease in a sigmoidal manner with bodyweight from 1.2 to 0.75, with half the decrease in exponent reached at 12.2 kg. No other covariates such as age were identified. A pharmacokinetic model for paracetamol characterizing changes in pharmacokinetic parameters across the pediatric age-range was developed. Clearance was found to change in a nonlinear manner with bodyweight. Based on the final model, dosing guidelines are proposed from preterm neonates to adolescents resulting in similar exposure across all age ranges.
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Affiliation(s)
- Chenguang Wang
- Division of Pharmacology, LACDR, Leiden University, Leiden, The Netherlands; Erasmus MC Sophia Children's Hospital, Intensive Care and Department of Paediatric Intensive Care, Rotterdam, The Netherlands
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Viberg H, Eriksson P, Gordh T, Fredriksson A. Paracetamol (Acetaminophen) Administration During Neonatal Brain Development Affects Cognitive Function and Alters Its Analgesic and Anxiolytic Response in Adult Male Mice. Toxicol Sci 2013; 138:139-47. [DOI: 10.1093/toxsci/kft329] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Comparison of the quantification of acetaminophen in plasma, cerebrospinal fluid and dried blood spots using high-performance liquid chromatography-tandem mass spectrometry. J Pharm Biomed Anal 2013; 83:1-9. [PMID: 23670126 DOI: 10.1016/j.jpba.2013.04.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 04/06/2013] [Accepted: 04/09/2013] [Indexed: 12/28/2022]
Abstract
Acetaminophen (paracetamol, N-(4-hydroxyphenyl) acetamide) is one of the most commonly prescribed drugs for the management of pain in children. Quantification of acetaminophen in pre-term and term neonates and small children requires the availability of highly sensitive assays in small volume blood samples. We developed and validated an LC-MS/MS assay for the quantification of acetaminophen in human plasma, cerebro-spinal fluid (CSF) and dried blood spots (DBS). Reconstitution in water (DBS only) and addition of a protein precipitation solution containing the deuterated internal standard were the only manual steps. Extracted samples were analyzed on a Kinetex 2.6 μm PFP column using an acetonitrile/formic acid gradient. The analytes were detected in the positive multiple reaction mode. Alternatively, DBS were automatically processed using direct desorption in a sample card and preparation (SCAP) robotic autosampler in combination with online extraction. The range of reliable response in plasma and CSF was 3.05-20,000 ng/ml (r(2)>0.99) and 27.4-20,000 ng/ml (r(2)>0.99) for DBS (manual extraction and automated direct desorption). Inter-day accuracy was always within 85-115% and inter-day precision for plasma, CSF and manually extracted DBS were less than 15%. Deming regression analysis comparing 167 matching pairs of plasma and DBS samples showed a correlation coefficient of 0.98. Bland Altman analysis indicated a 26.6% positive bias in DBS, most likely reflecting the blood: plasma distribution ratio of acetaminophen. DBS are a valid matrix for acetaminophen pharmacokinetic studies.
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Tekgunduz KS, Ceviz N, Demirelli Y, Olgun H, Caner I, Sahin IO, Yolcu C. Intravenous paracetamol for patent ductus arteriosus in premature infants - a lower dose is also effective. Concerning the article by M.Y. Oncel et al: Intravenous paracetamol treatment in the management of patent ductus arteriosus in extremely low birth weight infants [Neonatology 2013;103:166-169]. Neonatology 2013; 104:6-7. [PMID: 23548678 DOI: 10.1159/000348568] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 02/04/2013] [Indexed: 12/15/2022]
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Mrozek-Budzyn D, Majewska R, Kieltyka A, Augustyniak M. Neonatal exposure to Thimerosal from vaccines and child development in the first 3years of life. Neurotoxicol Teratol 2012; 34:592-7. [DOI: 10.1016/j.ntt.2012.10.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 10/03/2012] [Accepted: 10/05/2012] [Indexed: 11/27/2022]
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Funk RS, Brown JT, Abdel-Rahman SM. Pediatric pharmacokinetics: human development and drug disposition. Pediatr Clin North Am 2012; 59:1001-16. [PMID: 23036241 DOI: 10.1016/j.pcl.2012.07.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Human development is described by the various anatomic and physiologic changes that occur as the single-celled zygote matures into an adult human being. Concomitant with bodily maturation are changes in the complex interactions between pharmacologic agents and the biologic matrix that is the human body. Profound changes in the manner by which drugs traverse the body during development can have significant implications in drug efficacy and toxicity. Although not a replacement for well-conducted, pediatric, pharmacokinetic studies, an understanding of developmental biology and the mechanisms for drug disposition invariably assists the pediatric clinician with the judicious use of medications in children.
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Affiliation(s)
- Ryan S Funk
- Division of Clinical Pharmacology and Medical Toxicology, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA
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Allegaert K, van den Anker J. Pharmacokinetics and pharmacodynamics of intravenous acetaminophen in neonates. Expert Rev Clin Pharmacol 2012; 4:713-8. [PMID: 22111857 DOI: 10.1586/ecp.11.50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Effective analgesia in neonates is still hampered owing to a lack of data on pharmacokinetics and pharmacodynamics of analgesics. In this article, the consecutive steps taken to document aspects of disposition (pharmacokinetics and metabolism) and safety (hepatic tolerance, hemodynamic stability and effects on body temperature) during exposure to intravenous acetaminophen in neonates are summarized. Based on these data, dosing suggestions were formulated. However, we have to be aware that such dosing suggestions are - at present - without any validated pharmacodynamic correlates since the applicability of a fixed acetaminophen target concentration (10 mg·l(-1)) in neonates of different subpopulations remains to be documented. In addition, the number of observations in extreme preterm neonates is limited. Finally, epidemiological data suggest a link between perinatal acetaminophen exposure and an increased risk to developing asthma. Consequently, well designed and appropriately powered pharmacodynamic studies in neonates are urgently required, with specific emphasis on extreme preterm neonates.
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Affiliation(s)
- Karel Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Belgium.
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Kulo A, van de Velde M, de Hoon J, Verbesselt R, Devlieger R, Deprest J, Allegaert K. Pharmacokinetics of a loading dose of intravenous paracetamol post caesarean delivery. Int J Obstet Anesth 2012; 21:125-8. [PMID: 22341787 DOI: 10.1016/j.ijoa.2011.12.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 12/11/2011] [Accepted: 12/13/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND The postpartum period affects drug disposition, but data of intravenous paracetamol loading dose pharmacokinetics immediately following caesarean delivery have not yet been reported. METHODS Immediately following caesarean delivery, women received a 2-g loading dose of intravenous paracetamol. Plasma samples were collected at 1, 2, 4 and 6 h. Individual pharmacokinetics were calculated assuming a linear one-compartment model with instantaneous input and first-order output. Data were reported using median and range. RESULTS Twenty-eight patients undergoing caesarean delivery were recruited (age 31.5 [20-42] years, weight 79 [57-110] kg, body surface area 1.9 [1.5-2.4]m(2)). Median paracetamol plasma concentrations after 1, 2, 4 and 6 h were 22.5, 15.25, 7.9, and 3.9 mg/L respectively. Paracetamol clearance was 20.3 (11.8-62.8) L/h or 10.9 (7-23.8)L/hm(2), distribution volume 58.3 (42.9-156) L or 0.72 (0.52-1.56) L/kg. CONCLUSION Pharmacokinetics of intravenous paracetamol have been estimated following caesarean delivery. Although limited to a loading dose shortly after surgery, the results are clinically relevant since this is the first description in this patient population. These data provide evidence on which to base further integrated pharmacokinetic/pharmacodynamic studies in peripartum analgesia.
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Affiliation(s)
- A Kulo
- Center for Clinical Pharmacology, University Hospitals Leuven, Leuven, Belgium
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van Ganzewinkel CJJ, Mohns T, van Lingen RA, Derijks LJ, Andriessen P. Paracetamol serum concentrations in preterm infants treated with paracetamol intravenously: a case series. J Med Case Rep 2012; 6:1. [PMID: 22216927 PMCID: PMC3287161 DOI: 10.1186/1752-1947-6-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 01/04/2012] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Until now, studies on paracetamol given intravenously have mainly been performed with the pro-drug propacetamol or with paracetamol in preterm babies above 32 weeks of gestation. Studies in these babies indicate that intravenous paracetamol is tolerated well, however studies on the efficacy of intravenous paracetamol are lacking. There are no pharmacokinetic data on the administration of multiple doses of paracetamol in preterm babies with a gestational age below 32 weeks. CASE PRESENTATION We present a case series of nine Caucasian preterm babies, six boys and three girls, with a mean gestational age of 28.6 weeks (range 25.9 to 31.6 weeks). Case one, a girl with a gestational age of 25 weeks and six days, presented with necrotizing enterocolitis. In the second case, a female baby with a gestational age of 26 weeks and two days presented with hematoma. In case three, a female baby with a gestation of 26 weeks and one day developed intraventricular hemorrhage. In case four, a male baby with a gestational age of 31 weeks and four days presented with pain after vacuum delivery. Case five, a female baby born after a gestation of 29 weeks and six days presented with hematoma. In case six, a male baby with a gestation of 30 weeks and six days presented with hematoma. In case seven, a male baby, born with a gestational age of 30 weeks and six days, presented with caput succedaneum and hematoma. In case eight, a male baby, born after a gestation of 28 weeks and four days, developed abdominal distention. Case nine, a female baby, born with a gestational age of 27 weeks and three days presented with hematoma. These babies were treated with intravenous paracetamol 15 mg/kg every six hours. Serum concentrations and aspartate transaminase were determined after prolonged administration. Pain scores were assessed using the Premature Infant Pain Profile. CONCLUSION Paracetamol serum concentrations ranged from 8 to 64 mg/L after eight to 12 doses of intravenous paracetamol. Adequate analgesia was obtained in seven babies. During paracetamol therapy the median serum level of aspartate transaminase was 20 U/L (range 12 to 186 U/L). This case series indicates that prolonged intravenous administration of paracetamol in preterm babies with a gestational age of less than 32 weeks is tolerated well in the first days after birth. However, in the absence of proper pharmacokinetic data in this age group we cannot advocate the use of paracetamol intravenously.
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Affiliation(s)
- Christ-Jan Jlm van Ganzewinkel
- Department of Pediatrics, Division of Neonatology, Máxima Medical Centre, De Run 4600, 5504 DB Veldhoven, The Netherlands.
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Mahmood I. Prediction of drug clearance in children 3 months and younger: an allometric approach. ACTA ACUST UNITED AC 2011; 25:25-34. [PMID: 21417791 DOI: 10.1515/dmdi.2010.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sometimes it might not be possible to conduct a pharmacokinetic (PK) study in neonates and infants. Under these circumstances, one would like to predict PK parameters in this age group. Because drug clearance is the most important PK parameter, the objective of this study was to describe an allometric method to predict drug clearance in children ≤3 months. METHODS In total, 43 drugs (107 observations) were randomly selected for this study. The age of the children ranged from 0 to 1 year. Children were divided into two groups: ≤3 months and ≥3 months to 1 year. Drug clearance (CL) in children was predicted using the following equation: CL in the child=adult CL×(weight of the child/70)(0.75 or 1.0 or 1.2). RESULTS The results of the study indicated that the exponent 1.2 performs better in the prediction of drug clearance than exponent 1.0 or 0.75 for children ≤3 months. By contrast, exponent 1.0 provided better prediction for children ≥3 months to 1 year than exponent 1.2. Exponent 0.75 provided the worst results leading to substantial prediction error in children 0-1 year (in many instances more than 1000% prediction error). CONCLUSIONS Overall, it appears that exponent 1.2 is the best method out of three methods for reasonably accurate prediction of drug clearance in children ≤3 months old. However, exponent 1.2 will underpredict drug clearance in children older than 3 months. The suggested approach could be used to support the choice of the initial dose in clinical trials for children ≤3 months old.
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Affiliation(s)
- Iftekhar Mahmood
- Division of Hematology, Office of Blood Review and Research, Center for Biologic Evaluation and Research, Food and Drug Administration, Rockville, MD, USA.
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Abstract
BACKGROUND As a nonopioid parenteral analgesic intravenous (IV) acetaminophen is potentially attractive for emergency department (ED) use. However, there is little experience with its use in the pediatric ED setting. We introduced the agent into a pediatric ED with a preliminary restrictive prescribing regimen and describe its use. METHODS This is a retrospective record review of all patients who had received IV acetaminophen over 12 months. Prescribing indications were for analgesia only (not for fever management) in patients at risk of opioid-related adverse events. We assessed the demographics, dosing, presenting complaints, discharge diagnoses, and indications for IV acetaminophen use. RESULTS Thirty-one patients received IV acetaminophen (mean age, 10 years). All patients were at least moderately sick according to their triage assessment. The median dose was 15 mg/kg with a median of 1 dose administered. Presenting complaints were mainly trauma, abdominal complaints, and sepsis/fever/neutropenia. Thirty-nine percent of patients had severe underlying conditions. Two patients died: 1 patient had a chronic neurological condition, and the other was undergoing palliative treatment for cancer. Physicians complied with prescribing indications for half the patients: 53% were at risk of opioid-related adverse events. Physicians prescribed outside the initial indications as part of multimodal analgesia (13%), for complex patients with fever and pain (7%), and for fever only in patients unable to tolerate enteral administration (27%). CONCLUSIONS In the setting of an initial restrictive prescribing regimen, IV acetaminophen was used in a small number of pediatric ED patients. In addition to use in patients at risk of opioid adverse events, the medication was also used in complex patients who were unable to tolerate an enteral formulation. Emergency department prescribing guidelines have been modified accordingly.
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Allegaert K, Palmer G, Anderson B. Intravenous paracetamol pharmacokinetics in neonates: a pooled analysis. Crit Care 2011. [PMCID: PMC3067020 DOI: 10.1186/cc9766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Dórea JG. Making sense of epidemiological studies of young children exposed to thimerosal in vaccines. Clin Chim Acta 2010; 411:1580-6. [DOI: 10.1016/j.cca.2010.07.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 07/08/2010] [Accepted: 07/10/2010] [Indexed: 12/16/2022]
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Allegaert K, Naulaers G. Haemodynamics of intravenous paracetamol in neonates. Eur J Clin Pharmacol 2010; 66:855-8. [PMID: 20607221 DOI: 10.1007/s00228-010-0860-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 06/17/2010] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Reports on the haemodynamics of intravenous (iv) paracetamol in adult intensive care were recently published. We therefore wanted to explore the haemodynamics of iv paracetamol in neonates. METHODS Retrospective, pooled analysis of heart rate (bpm) and blood pressure (mean, systolic, diastolic) observations collected during iv paracetamol pharmacokinetic studies in neonates. Heart rate and blood pressure were recorded just before and 30, 60, 120, 180, 240, 300 and 360 min after iv paracetamol (paired, ANOVA). Clinical characteristics in hypotensive (mean mmHg < gestational age, weeks) cases were compared with controls (Mann-Whitney U test). RESULTS Based on observations in 72 neonates, heart rate decreased from 145 (SD 20) to 138 (21), 141 (20), 137 (20), 137 (22), 140 (20), 139 (20) and 140 (21) bpm (paired p < 0.05, ANOVA p = 0.36). There were no changes in systolic and diastolic pressure, but mean arterial pressure decreased from 46 (7) to 43 (8) mmHg at 60 min (paired p < 0.05, ANOVA p = 0.75). Eight neonates developed hypotension. These patients had lower pre-administration arterial pressure (38 vs 47 mmHg, p < 0.05). CONCLUSIONS In a setting of open label administration to alleviate (procedural) pain, haemodynamic effects of iv paracetamol in neonates remained modest. We suggest considering impaired haemodynamics to be a relative contra-indication for iv paracetamol in neonates.
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Affiliation(s)
- Karel Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Wilson-Smith EM, Morton NS. Survey of i.v. paracetamol (acetaminophen) use in neonates and infants under 1 year of age by UK anesthetists. Paediatr Anaesth 2009; 19:329-37. [PMID: 19335345 DOI: 10.1111/j.1460-9592.2009.02947.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The license for i.v. paracetamol has recently been extended to include term neonates and infants aged 1 year, at a uniform dose across this age range of 7.5 mg.kg(-1), total daily dose 30 mg.kg(-1).day(-1). We were interested to survey current i.v. paracetamol prescribing practices of anesthetists in the UK, in neonates and infants under 1 year of age. METHODS We conducted an online survey of 94 linkmen of the Association of Pediatric Anesthetists of Great Britain and Ireland Linkmen representing both general and specialist hospitals and 90 members of the British Pediatric Pain Travelling Club representing the pediatric acute pain teams throughout the UK and Ireland. RESULTS A total of 105/184 (57%) responded to the survey on behalf of 78 regions and 27 pediatric acute pain teams. Over half (54%) of the respondents indicated i.v. paracetamol use in infants under 1 year of age. A wide range of loading and maintenance doses were used. Total daily doses exceeded the license for age 1-12 months in 70% of cases; for the 36 week postconceptional age (PCA)-1 month age range the proportion was 50%. Over 80% of total daily dosing from age 36 weeks PCA to 1 year fell within dosing suggested by pharmacokinetic studies. Close to 40% of respondents who used i.v. paracetamol in infants, also indicated use in preterm age groups. The total daily dose used in preterm neonates was within the range suggested by pharmacokinetic studies, in over 90% of cases in the age range 32-36 weeks PCA, and for 60% in the under 32 weeks PCA age group. CONCLUSIONS This survey demonstrates i.v. paracetamol dosing in infants in the UK and Ireland is frequently above the licensed dose and outside the licensed age range but is in keeping with doses suggested by pharmacokinetic studies.
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Palmer GM, Atkins M, Anderson BJ, Smith KR, Culnane TJ, McNally CM, Perkins EJ, Chalkiadis GA, Hunt RW. I.V. acetaminophen pharmacokinetics in neonates after multiple doses. Br J Anaesth 2008; 101:523-30. [PMID: 18628265 DOI: 10.1093/bja/aen208] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pharmacokinetics of an i.v. prodrug of acetaminophen (propacetamol) in neonates after repeat dosing are reported, with scant data for i.v. acetaminophen formulation. METHODS Neonates from an intensive care unit received 6-hourly prn i.v. acetaminophen dosed according to postmenstrual age (PMA): 28-32 weeks, 10 mg kg(-1); 32-36 weeks, 12.5 mg kg(-1); and > or =36 weeks, 15 mg kg(-1). A maximum of five blood samples for assay and liver function tests (LFTs) were collected. A one-compartment linear disposition model (zero-order input; first-order elimination) was used to describe time-concentration profiles using population modelling (NONMEM). RESULTS Fifty neonates, median (range) PMA 38.6 (32-45) weeks, mean (SD) weight 2.9 (0.7) kg, received a mean of 15 doses over a median 4 days with 189 serum acetaminophen and 231 LFT measurements. Standardized population parameter estimates for a term neonate were clearance (CL) 5.24 (CV 30.5%) litre h(-1) 70 kg(-1) and volume of distribution (V) 76 (29.6%) litre 70 kg(-1). CL increased with PMA from 4.4 litre h(-1) 70 kg(-1) at 34 weeks to 6.3 litre h(-1) 70 kg(-1) at 46 weeks. The presence of unconjugated hyperbilirubinaemia was associated with reduced CL: 150 micromol litre(-1) associated with 40% CL reduction. Acetaminophen concentrations between 10 and 23 mg litre(-1) at steady state are predicted after 15 mg kg(-1) 6-hourly for a neonate of PMA 40 weeks. Hepatic enzyme analysis of daily samples changed significantly for one patient whose alanine aminotransferase concentration tripled. CONCLUSIONS The parameter estimates are similar to those described for propacetamol. There was no evidence of hepatotoxicity. Unconjugated hyperbilirubinaemia impacts upon CL, dictating dose reduction.
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Affiliation(s)
- G M Palmer
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia.
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Prins SA, Van Dijk M, Van Leeuwen P, Searle S, Anderson BJ, Tibboel D, Mathot RAA. Pharmacokinetics and analgesic effects of intravenous propacetamol vs rectal paracetamol in children after major craniofacial surgery. Paediatr Anaesth 2008; 18:582-92. [PMID: 18482233 DOI: 10.1111/j.1460-9592.2008.02619.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The pharmacokinetics and analgesic effects of intravenous and rectal paracetamol were compared in nonventilated infants after craniofacial surgery in a double-blind placebo controlled study. METHODS During surgery all infants (6 months-2 years) received a rectal loading dose of 40 mg.kg(-1) paracetamol 2 h before anticipated extubation. On admittance to the pediatric surgical ICU, the children were randomized to receive either a 15 min intravenous infusion of 40 mg.kg(-1) propacetamol, a prodrug of paracetamol, or 20 mg.kg(-1) paracetamol rectally every 6 h. A population pharmacokinetic analysis of the paracetamol plasma concentration time-profiles was undertaken using nonlinear mixed effects models. The visual analogue scale (VAS) (score 0-10 cm) and COMFORT Behavior scale (score 6-30) were used to monitor analgesia in the 24-h period following surgery. RESULTS Twelve infants received intravenous propacetamol and 14 paracetamol suppositories. Paracetamol pharmacokinetics were described according to a two-compartmental model with linear disposition. Pharmacokinetic parameters were standardized to a 70 kg person using allometric '1/4 power' models. Parameter estimates were: absorption half-life from the rectum 4.6 h, propacetamol hydrolysis half-life 0.028 h, clearance 12 l.h(-1).70 kg(-1), intercompartmental clearance 116 l.h(-1).70 kg(-1), central and peripheral volume of distribution 7.9 and 44 l.70 kg(-1), respectively. During the 24-h study period 22 infants exhibited VAS scores <4 cm, which was considered a cutoff point. On single occasions four patients, two in each group, exhibited a VAS score >/=4 cm. Nine patients in the rectal treatment group and three patients in the intravenous treatment group received midazolam for COMFORT-B scores exceeding 17 (P < 0.05). CONCLUSIONS Intravenous propacetamol proved to be more effective than rectal paracetamol in infants after craniofacial surgery. Midazolam was more frequently administered to patients receiving paracetamol suppositories, indicating that these children experienced more distress, possibly caused by pain.
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Affiliation(s)
- Sandra A Prins
- Department of Pediatric Surgery, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
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Allegaert K, Rayyan M, De Rijdt T, Van Beek F, Naulaers G. Hepatic tolerance of repeated intravenous paracetamol administration in neonates. Paediatr Anaesth 2008; 18:388-92. [PMID: 18384338 DOI: 10.1111/j.1460-9592.2008.02535.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION An intravenous (i.v.) formulation of paracetamol is available, but reports on its hepatic tolerance in neonates are limited. We therefore assessed hepatic tolerance of i.v. paracetamol in neonates. METHODS In a single centre retrospective study, clinical data and hepatic enzyme profiles (ALT, AST, gammaGT) were collected in neonates treated with i.v. paracetamol between January 1, 2006 and October 1, 2007. Hepatic enzyme profiles were retrieved from 2 days before until 2 days after i.v. paracetamol administration. Mann-Whitney U-test was used to compare hepatic enzymes before, during, and after i.v. treatment. Correlations (Spearman rank) of hepatic enzymes with duration of treatment during i.v. administration were investigated. RESULTS In 189 cases, 2360 administrations {postmenstrual age 38 (range 30-55) weeks, postnatal age 5 (1-182) days} were documented and 1132 hepatic enzyme observations were available in 149/189 cases. There was no significant increase in ALT, AST, or gammaGT when pretreatment observations (n = 310) were compared with observations during (n = 649) or during with after (n = 173) treatment, nor was there a significant increase during administration. CONCLUSIONS This retrospective study on hepatic tolerance provides evidence on safety aspects of i.v. paracetamol in neonates. Future studies should focus on dose-findings and pharmacodynamics of this formulation in neonates.
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Affiliation(s)
- Karel Allegaert
- Neonatal Intensive Care Unit, University Hosptials Leuven, Leuven, Belgium.
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Bartocci M, Lundeberg S. Intravenous paracetamol: the 'Stockholm protocol' for postoperative analgesia of term and preterm neonates. Paediatr Anaesth 2007; 17:1120-1. [PMID: 17897288 DOI: 10.1111/j.1460-9592.2007.02322.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Anderson BJ, Palmer GM. Recent pharmacological advances in paediatric analgesics. Biomed Pharmacother 2006; 60:303-9. [PMID: 16854558 DOI: 10.1016/j.biopha.2006.06.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2006] [Accepted: 06/12/2006] [Indexed: 11/22/2022] Open
Abstract
Growth and development are two linked processes that distinguish children from adults. The use of size as the primary covariate during pharmacokinetic (PK) analyses allows exploration of the effects of age. Allometric scaling models have assisted understanding of the developmental clearance changes in common analgesic drugs such as paracetamol, morphine, tramadol and local anaesthetics agents. Single nucleotide polymorphisms (pharmacogenomics [PG]) and their impact on hepatic drug metabolism for opioids, tramadol, non-steroidal anti-inflammatory drugs (NSAIDs) and drug receptor responses are increasingly reported. Altered chemical structure or formulations of common analgesics alter pharmacodynamic (PD) effects enhancing safety and efficacy for NSAIDs by stereoselectivity and the addition of nitric oxide, for intravenous paracetamol by formulation and structural difference from propacetamol and for local anaesthetics through stereoselectivity. This article focuses upon recent data for analgesics used in paediatric pain management including paracetamol, NSAIDs, morphine, tramadol, amide local anaesthetics and ketamine. It centres on PK and clinical studies in neonates, infants and children. PG studies are acknowledged as potentially allowing individual drug therapy tailoring through a decrease in between-patient population variability, although the impact of PG in the very young is less certain. There are few data describing age-related PD changes in children despite recognition that the number, affinity and type of receptors or the availability of natural ligands changes with age.
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Affiliation(s)
- B J Anderson
- University of Auckland, Auckland, New Zealand, and Department of Anaesthesia and Pain Management, Royal Children's Hospital, Victoria, Australia.
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Anderson BJ, Palmer GM. Recent developments in the pharmacological management of pain in children. Curr Opin Anaesthesiol 2006; 19:285-92. [PMID: 16735812 DOI: 10.1097/01.aco.0000192802.33291.6f] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review explores progress in developmental pharmacokinetics, pharmacogenomics and formulations of analgesic agents, and discusses potential implications for pain therapy. RECENT FINDINGS Characterization of the developmental pharmacokinetics of morphine, tramadol, paracetamol and nonsteroidal anti-inflammatory drugs has improved dosing in children. Oral sugar solutions have replaced the brandy/sugar pacifier and are effective for single painful events in neonates. Intravenous paracetamol offers increased dosing accuracy, and avoids absorption and bioavailability variability. New nitric-oxide-releasing versions of paracetamol and nonsteroidal anti-inflammatory drugs offer safer alternatives to their parent drugs with enhanced potency. Ketamine has come under a cloud for its possible effects on the neonatal developing brain, but it is being used increasingly in children to supplement opioids for pain after major surgery. Hopes that morphine analgesia may improve neurological outcome in premature babies have not materialized. Reports concerning chronic pain are generally case series and controlled trials are rare and nearly nonexistent in children. SUMMARY Unlicensed drug use in the very young will increase as familiarity increases. Pharmacogenomic studies have the potential to tailor drug therapy to the individual and decrease between-patient variability. Unfortunately, the pharmacodynamic knowledge in children of analgesic agents remains neglected and is usually extrapolated from adult data.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand, and Department of Anaesthesia and Pain Management, Royal Children's Hospital, Victoria, Australia.
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Berde CB, Jaksic T, Lynn AM, Maxwell LG, Soriano SG, Tibboel D. Anesthesia and analgesia during and after surgery in neonates. Clin Ther 2006; 27:900-21. [PMID: 16117991 DOI: 10.1016/j.clinthera.2005.06.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Historically, the use of anesthetics and analgesics in neonates and infants has been based on extrapolations from studies performed in adults and older children. Over the past 20 years, there has been a growing body of research on the clinical pharmacology and clinical outcomes of these agents in neonates and infants. OBJECTIVE This article summarizes clinical pharmacology and clinical outcomes studies of opioids, opioid antagonists, sedative-hypnotics, nonsteroidal anti-inflammatory drugs and acetaminophen, and local anesthetics in neonates and infants to highlight gaps in the available knowledge, review some concerns about study design, and identify drugs that should receive high priority for future study. METHODS Relevant studies were identified through a search of MEDLINE and a review of textbooks, conference proceedings, and abstracts. The available literature was subjected to expert committee-based review. CONCLUSIONS There is a growing body of information on analgesic and anesthetic pharmacokinetics, pharmacodynamics, and clinical outcomes in neonates and infants, permitting safe and effective use in some clinical settings. Major gaps in knowledge persist, however. Future research may involve a combination of clinical trials and preclinical studies in suitable infant animal surrogate models.
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Affiliation(s)
- Charles B Berde
- Department of Anaesthesia, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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