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Shaniv D, Allegaert K. Applied pharmacokinetics to improve pharmacotherapy in neonatal and paediatric intensive care units: focus on correct dose selection. Arch Dis Child Educ Pract Ed 2024; 109:184-190. [PMID: 38408792 DOI: 10.1136/archdischild-2023-326325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/13/2024] [Indexed: 02/28/2024]
Abstract
Drug dosing and exposure throughout childhood are constantly affected by maturational changes like weight, age or body surface area. In neonatal and paediatric intensive care units (NICU and PICU, respectively), drug dosing and exposure are further impacted by non-maturational changes. These changes are related to factors such as sepsis, cardiac failure, acute kidney injury, extracorporeal circuits or drug-drug interactions (DDIs) resulting from polypharmacy.This potentially complex situation may alter drug pharmacokinetics to result in greater-than-usual intrapatient and interpatient drug exposure variability. These effects may call for individual dosage adjustments. Dosage adjustments may apply to both loading doses or maintenance doses, which should be used as appropriate, depending on the specific characteristics of a given drug. Phenobarbital and vancomycin dosing are hereby used as illustrations.To optimise dose selection in NICU/PICU settings, we suggest to consider therapeutic drug monitoring integrated in model-informed precision dosing, and to familiarise oneself with existing paediatric drug formularies as well as DDI databases/search engines. Paediatric clinical pharmacologists and pharmacists can hereby guide clinicians with no prior experience on how to properly apply these data sources to day-to-day practice in individual patients or specific subpopulations of NICU or PICU patients.
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Affiliation(s)
- Dotan Shaniv
- Pharmacy Services, Kaplan Medical Center, Clalit Health Services, Rehovot, Israel
- Neonatal Intensive Care Unit, Kaplan Medical Center, Clarit Health Services, Rehovot, Israel
| | - 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, Rotterdam, Netherlands
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Stroe MS, Huang MC, Annaert P, Leys K, Smits A, Allegaert K, Van Bockstal L, Valenzuela A, Ayuso M, Van Ginneken C, Van Cruchten S. Drug Disposition in Neonatal Göttingen Minipigs: Exploring Effects of Perinatal Asphyxia and Therapeutic Hypothermia. Drug Metab Dispos 2024; 52:824-835. [PMID: 38906699 DOI: 10.1124/dmd.124.001677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/25/2024] [Accepted: 05/29/2024] [Indexed: 06/23/2024] Open
Abstract
Asphyxiated neonates often undergo therapeutic hypothermia (TH) to reduce morbidity and mortality. Since both perinatal asphyxia (PA) and TH influence physiology, altered pharmacokinetics (PK) and pharmacodynamics (PD) are expected. Given that TH is the standard of care for PA with moderate to severe hypoxic-ischemic encephalopathy, disentangling the effect of PA versus TH on PK/PD is not possible in clinical settings. However, animal models can provide insights into this matter. The (neonatal) Göttingen Minipig, the recommended strain for nonclinical drug development, was selected as translational model. Four drugs-midazolam (MDZ), fentanyl (FNT), phenobarbital (PHB), and topiramate (TPM)-were intravenously administered under four conditions: control (C), therapeutic hypothermia (TH), hypoxia (H), and hypoxia plus TH (H+TH). Each group included six healthy male neonatal Göttingen Minipigs anesthetized for 24 hours. Blood samples were drawn at 0 (predose) and 0.5, 2, 2.5, 3, 4, 4.5, 6, 8, 12, and 24 hours post drug administration. Drug plasma concentrations were determined using validated bioanalytical assays. The PK parameters were estimated through compartmental and noncompartmental PK analysis. The study showed a statistically significant decrease in FNT clearance (CL; 66% decrease), with an approximately threefold longer half-life (t1/2) in the TH group. The H+TH group showed a 17% reduction in FNT CL, with a 62% longer t1/2 compared with the C group; however, it was not statistically significant. Although not statistically significant, trends toward lower CL and longer t1/2 were observed in the TH and H+TH groups for MDZ and PHB. Additionally, TPM demonstrated a 28% decrease in CL in the H group compared with controls. SIGNIFICANCE STATEMENT: The overarching goal of this study using the neonatal Göttingen Minipig model was to disentangle the effects of systemic hypoxia and TH on PK using four model drugs. Such insights can subsequently be used to inform and develop a physiologically based pharmacokinetic model, which is useful for drug exposure prediction in human neonates.
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Affiliation(s)
- Marina-Stefania Stroe
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Miao-Chan Huang
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Pieter Annaert
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Karen Leys
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Anne Smits
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Karel Allegaert
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Lieselotte Van Bockstal
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Allan Valenzuela
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Miriam Ayuso
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Chris Van Ginneken
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
| | - Steven Van Cruchten
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium (M.S.-S., L.V.B., A.V., M.A., C.V.G., S.V.C.); Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium (M.-C.H., P.A., K.L.); BioNotus GCV, Niel, Belgium (P.A.); Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium (A.S.); Departments of Development and Regeneration (A.S., K.A.) and Pharmaceutical and Pharmacological Sciences (K.A.), KU Leuven, Leuven, Belgium; and Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands (K.A.)
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Bersani I, Lapergola G, Patacchiola R, D'Adamo E, Stuppia L, de Laurenzi V, Damiani V, Cataldo I, Clemente K, Primavera A, Salomone R, Barbante E, Campi F, Savarese I, Ronci S, Dotta A, Braguglia A, Longo D, Gavilanes DAW, Gazzolo F, Serpero L, Strozzi MC, Maconi A, Cassinari M, Libener R, Gazzolo D. Elevated S100B urine levels predict seizures in infants complicated by perinatal asphyxia and undergoing therapeutic hypothermia. Clin Chem Lab Med 2024; 62:1109-1117. [PMID: 38290722 DOI: 10.1515/cclm-2023-1471] [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: 12/19/2023] [Accepted: 01/23/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVES Seizures (SZ) are one of the main complications occurring in infants undergoing therapeutic hypothermia (TH) due to perinatal asphyxia (PA) and hypoxic ischemic encephalopathy (HIE). Phenobarbital (PB) is the first-line therapeutic strategy, although data on its potential side-effects need elucidation. We investigated whether: i) PB administration in PA-HIE TH-treated infants affects S100B urine levels, and ii) S100B could be a reliable early predictor of SZ. METHODS We performed a prospective case-control study in 88 PA-HIE TH infants, complicated (n=44) or not (n=44) by SZ requiring PB treatment. S100B urine levels were measured at 11 predetermined monitoring time-points from first void up to 96-h from birth. Standard-of-care monitoring parameters were also recorded. RESULTS S100B significantly increased in the first 24-h independently from HIE severity in the cases who later developed SZ and requested PB treatment. ROC curve analysis showed that S100B, as SZ predictor, at a cut-off of 2.78 μg/L achieved a sensitivity/specificity of 63 and 84 %, positive/negative predictive values of 83 and 64 %. CONCLUSIONS The present results offer additional support to the usefulness of S100B as a trustable diagnostic tool in the clinical daily monitoring of therapeutic and pharmacological procedures in infants complicated by PA-HIE.
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Affiliation(s)
- Iliana Bersani
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giuseppe Lapergola
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Roberta Patacchiola
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Ebe D'Adamo
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Liborio Stuppia
- Center for Advances Studies and Technology (CAST), G. d'Annunzio University, Chieti, Italy
| | - Vincenzo de Laurenzi
- Center for Advances Studies and Technology (CAST), G. d'Annunzio University, Chieti, Italy
| | - Verena Damiani
- Center for Advances Studies and Technology (CAST), G. d'Annunzio University, Chieti, Italy
| | - Ivana Cataldo
- Laboratory of Clinical Pathology, SS Annunziata Hospital, Chieti, Italy
| | - Katia Clemente
- Laboratory of Clinical Pathology, SS Annunziata Hospital, Chieti, Italy
| | - Adele Primavera
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Rita Salomone
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Elisabetta Barbante
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Francesca Campi
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Immacolata Savarese
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sara Ronci
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Dotta
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Annabella Braguglia
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Daniela Longo
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Danilo A W Gavilanes
- Department of Pediatrics and Neonatology, Maastricht University, Maastricht, The Netherlands
| | | | - Laura Serpero
- Department of Maternal, Fetal and Neonatal Medicine, SS Antonio, Biagio and C. Arrigo Hospital, Alessandria, Italy
| | - Maria Chiara Strozzi
- Department of Pediatrics and Neonatology, Ospedale Cardinal Massaia, Asti, Italy
| | - Antonio Maconi
- Social Security Administration Development and Promotion of Scientific Research Unit, SS Antonio, Biagio and C. Arrigo Hospital, Alessandria, Italy
| | - Maurizio Cassinari
- Department of Clinical Biochemistry, Transfusion and Regeneration Medicine Alessandria Hospital, Alessandria, Italy
| | - Roberta Libener
- Department of Clinical Biochemistry, Transfusion and Regeneration Medicine Alessandria Hospital, Alessandria, Italy
| | - Diego Gazzolo
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
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Cohen H, Mahajna G, Ben-Shushan T, Matok I, Eyal S. The extent of cytochrome P450 3A induction by antiseizure medications: A systematic review and network meta-analysis. Epilepsia 2024; 65:445-455. [PMID: 38010146 DOI: 10.1111/epi.17822] [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: 09/15/2023] [Revised: 10/24/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE Antiseizure medications (ASMs) are commonly categorized as enzyme-inducers and non-enzyme-inducers based on their propensity to enhance the metabolism of concomitantly administered drugs. This systematic review and network meta-analysis aimed to rank ASMs as cytochrome P450 3A (CYP3A)-inducers based on a comparative assessment of ASM-induced reduction in the concentrations of sensitive substrate drugs. METHODS The protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews; CRD42022335846), and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) standards were followed. We searched MEDLINE, Embase, and Cochrane until March 14, 2023 without an initial date restriction. Data were additionally obtained via the US Food and Drug Administration database. Studies had to be prospective, with ASM monotherapy for ≥5 days. The primary parameter was the magnitude of change in the area under the concentration-time curve of CYP3A substrates following treatment with the ASM. The standardized mean difference (SMD) was used as the point estimate for the indirect comparisons between ASMs using the pairwise method. Bias risk was assessed using the PKclin tool. RESULTS We identified 14 open-label, fixed-sequence studies with 370 participants. The effect size of 600 mg/day carbamazepine did not differ from those of 300 mg/day phenytoin (SMD = -.06, 95% confidence interval [CI] = -.18 to .07) and 200 mg/day cenobamate (SMD = -.11, 95% CI = -.26 to .04). Carbamazepine at 600 mg/day was the strongest CYP3A-inducer (P-score = .88), followed by carbamazepine 400 mg/day (.83), phenytoin 300 mg/day (.79), and cenobamate 200 mg/day (.73). Eslicarbazepine (800 mg/day) ranked higher than cenobamate 100 mg/day and oxcarbazepine 900 mg/day (.60, .39, and .37, respectively). SIGNIFICANCE Despite the limited number of studies, our network meta-analysis emphasizes that the magnitude of ASM effects on CYP3A substrate metabolism is a dose-dependent continuum. When possible, ASM classification as inducers should apply cutoff values tailored to the outcome. Prescribers should monitor plasma concentrations or clinical effects of CYP3A substrates and consider selecting concomitant medications accordingly.
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Affiliation(s)
- Hagar Cohen
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ghadeer Mahajna
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tomer Ben-Shushan
- Medical Library Authority, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Matok
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sara Eyal
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
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5
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Pressler RM, Abend NS, Auvin S, Boylan G, Brigo F, Cilio MR, De Vries LS, Elia M, Espeche A, Hahn CD, Inder T, Jette N, Kakooza-Mwesige A, Mader S, Mizrahi EM, Moshé SL, Nagarajan L, Noyman I, Nunes ML, Samia P, Shany E, Shellhaas RA, Subota A, Triki CC, Tsuchida T, Vinayan KP, Wilmshurst JM, Yozawitz EG, Hartmann H. Treatment of seizures in the neonate: Guidelines and consensus-based recommendations-Special report from the ILAE Task Force on Neonatal Seizures. Epilepsia 2023; 64:2550-2570. [PMID: 37655702 DOI: 10.1111/epi.17745] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
Seizures are common in neonates, but there is substantial management variability. The Neonatal Task Force of the International League Against Epilepsy (ILAE) developed evidence-based recommendations about antiseizure medication (ASM) management in neonates in accordance with ILAE standards. Six priority questions were formulated, a systematic literature review and meta-analysis were performed, and results were reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 standards. Bias was evaluated using the Cochrane tool and risk of Bias in non-randomised studies - of interventions (ROBINS-I), and quality of evidence was evaluated using grading of recommendations, assessment, development and evaluation (GRADE). If insufficient evidence was available, then expert opinion was sought using Delphi consensus methodology. The strength of recommendations was defined according to the ILAE Clinical Practice Guidelines development tool. There were six main recommendations. First, phenobarbital should be the first-line ASM (evidence-based recommendation) regardless of etiology (expert agreement), unless channelopathy is likely the cause for seizures (e.g., due to family history), in which case phenytoin or carbamazepine should be used. Second, among neonates with seizures not responding to first-line ASM, phenytoin, levetiracetam, midazolam, or lidocaine may be used as a second-line ASM (expert agreement). In neonates with cardiac disorders, levetiracetam may be the preferred second-line ASM (expert agreement). Third, following cessation of acute provoked seizures without evidence for neonatal-onset epilepsy, ASMs should be discontinued before discharge home, regardless of magnetic resonance imaging or electroencephalographic findings (expert agreement). Fourth, therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy (evidence-based recommendation). Fifth, treating neonatal seizures (including electrographic-only seizures) to achieve a lower seizure burden may be associated with improved outcome (expert agreement). Sixth, a trial of pyridoxine may be attempted in neonates presenting with clinical features of vitamin B6-dependent epilepsy and seizures unresponsive to second-line ASM (expert agreement). Additional considerations include a standardized pathway for the management of neonatal seizures in each neonatal unit and informing parents/guardians about the diagnosis of seizures and initial treatment options.
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Affiliation(s)
- Ronit M Pressler
- Clinical Neuroscience, UCL-Great Ormond Street Institute of Child Health, London, UK
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stéphan Auvin
- Department Medico-Universitaire Innovation Robert-Debré, Robert Debré Hospital, Public Hospital Network of Paris, Pediatric Neurology, University of Paris, Paris, France
| | - Geraldine Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
- Innovation Research and Teaching Service (SABES-ASDAA), Teaching Hospital of Paracelsus Medical Private University, Bolzano-Bozen, Italy
| | - Maria Roberta Cilio
- Division of Pediatric Neurology, Saint-Luc University Hospital, and Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Linda S De Vries
- Department of Neonatology, University Medical Center, Utrecht, the Netherlands
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute-IRCCS, Troina, Italy
| | - Alberto Espeche
- Department of Neurology, Hospital Materno Infantil, Salta, Argentina
| | - Cecil D Hahn
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Terrie Inder
- Department of Pediatrics, Newborn Medicine, Children's Hospital of Orange County, University of California, Irvine, Irvine, California, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Angelina Kakooza-Mwesige
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Silke Mader
- Scientific Affairs, European Foundation for the Care of Newborn Infants, Munich, Germany
| | - Eli M Mizrahi
- Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
- Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine, and Montefiore Medical Center, Bronx, New York, USA
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital and University of Western Australia, Nedlands, Western Australia, Australia
| | - Iris Noyman
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Pediatric Neurology Unit, Pediatric Division, Soroka Medical Center, Beer-Sheva, Israel
| | - Magda L Nunes
- Pontifícia Universidade Católica do Rio Grande do Sul-PUCRS School of Medicine and the Brain Institute, Porto Alegre, Brazil
| | - Pauline Samia
- Departments of Pediatrics and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Eilon Shany
- Department of Neonatology, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Renée A Shellhaas
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Ann Subota
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chahnez Charfi Triki
- Child Neurology Department, Hedi Chaker Hospital, Sfax Medical School, University of Sfax, Sfax, Tunisia
| | - Tammy Tsuchida
- Departments of Neurology and Pediatrics, Children's National Health System, George Washington University School of Medicine, Washington, District of Columbia, USA
| | | | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Elissa G Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Hans Hartmann
- Clinic for Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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De Sutter PJ, Rossignol P, Breëns L, Gasthuys E, Vermeulen A. Predicting Volume of Distribution in Neonates: Performance of Physiologically Based Pharmacokinetic Modelling. Pharmaceutics 2023; 15:2348. [PMID: 37765316 PMCID: PMC10536587 DOI: 10.3390/pharmaceutics15092348] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/12/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023] Open
Abstract
The volume of distribution at steady state (Vss) in neonates is still often estimated through isometric scaling from adult values, disregarding developmental changes beyond body weight. This study aimed to compare the accuracy of two physiologically based pharmacokinetic (PBPK) Vss prediction methods in neonates (Poulin & Theil with Berezhkovskiy correction (P&T+) and Rodgers & Rowland (R&R)) with isometrical scaling. PBPK models were developed for 24 drugs using in-vitro and in-silico data. Simulations were done in Simcyp (V22) using predefined populations. Clinical data from 86 studies in neonates (including preterms) were used for comparison, and accuracy was assessed using (absolute) average fold errors ((A)AFEs). Isometric scaling resulted in underestimated Vss values in neonates (AFE: 0.61), and both PBPK methods reduced the magnitude of underprediction (AFE: 0.82-0.83). The P&T+ method demonstrated superior overall accuracy compared to isometric scaling (AAFE of 1.68 and 1.77, respectively), while the R&R method exhibited lower overall accuracy (AAFE: 2.03). Drug characteristics (LogP and ionization type) and inclusion of preterm neonates did not significantly impact the magnitude of error associated with isometric scaling or PBPK modeling. These results highlight both the limitations and the applicability of PBPK methods for the prediction of Vss in the absence of clinical data.
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Leys K, Stroe MS, Annaert P, Van Cruchten S, Carpentier S, Allegaert K, Smits A. Pharmacokinetics during therapeutic hypothermia in neonates: from pathophysiology to translational knowledge and physiologically-based pharmacokinetic (PBPK) modeling. Expert Opin Drug Metab Toxicol 2023; 19:461-477. [PMID: 37470686 DOI: 10.1080/17425255.2023.2237412] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/13/2023] [Accepted: 07/13/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Perinatal asphyxia (PA) still causes significant morbidity and mortality. Therapeutic hypothermia (TH) is the only effective therapy for neonates with moderate to severe hypoxic-ischemic encephalopathy after PA. These neonates need additional pharmacotherapy, and both PA and TH may impact physiology and, consequently, pharmacokinetics (PK) and pharmacodynamics (PD). AREAS COVERED This review provides an overview of the available knowledge in PubMed (until November 2022) on the pathophysiology of neonates with PA/TH. In vivo pig models for this setting enable distinguishing the effect of PA versus TH on PK and translating this effect to human neonates. Available asphyxia pig models and methodological considerations are described. A summary of human neonatal PK of supportive pharmacotherapy to improve neurodevelopmental outcomes is provided. EXPERT OPINION To support drug development for this population, knowledge from clinical observations (PK data, real-world data on physiology), preclinical (in vitro and in vivo (minipig)) data, and molecular and cellular biology insights can be integrated into a predictive physiologically-based PK (PBPK) framework, as illustrated by the I-PREDICT project (Innovative physiology-based pharmacokinetic model to predict drug exposure in neonates undergoing cooling therapy). Current knowledge, challenges, and expert opinion on the future directions of this research topic are provided.
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Affiliation(s)
- Karen Leys
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences KU Leuven, Leuven, Belgium
| | - Marina-Stefania Stroe
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences KU Leuven, Leuven, Belgium
- BioNotus GCV, Niel, Belgium
| | - Steven Van Cruchten
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | | | - 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, GA, Rotterdam, The Netherlands
- Child and Youth Institute, KU Leuven, Leuven, Belgium
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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Affiliation(s)
- Elissa Yozawitz
- From the Isabelle Rapin Division of Child Neurology of the Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Variations in care of neonates during therapeutic hypothermia: call for care practice bundle implementation. Pediatr Res 2023:10.1038/s41390-022-02453-6. [PMID: 36624286 DOI: 10.1038/s41390-022-02453-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/15/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Therapeutic hypothermia (TH) is the gold-standard treatment for moderate and severe neonatal encephalopathy (NE). Care during TH has implications for long-term outcomes. Outcome variability exists among neonatal intensive care units (NICUs) in Canada, but care variations are not understood well. This study examines variations in care practices for neonates with NE treated with TH in NICUs across Canada. METHODS A non-anonymous, web-based questionnaire was emailed to tertiary NICUs in Canada providing TH for NE to assess care practices during the first days of life and neurodevelopmental follow-up. RESULTS Ninety-two percent (24/26) responded. Centres followed national guidelines regarding the use of the modified Sarnat score to assess the initial severity of NE, the need to initiate TH within the first 6 h of birth, and the importance of follow-up. However, other practices varied, including ventilation mode, definition/treatment of hypotension, routine echocardiography, use of sedation, use of electroencephalogram (EEG), MRI timing, placental analysis, and follow-up duration. CONCLUSIONS NICUs across Canada follow available national guidelines, but variations exist in practices for managing NE during TH. Development and implementation of a consensus-based care bundle for neonates during TH may reduce practice variability and improve outcomes. IMPACT This survey describes the current HIE care practices and variation among tertiary centres in Canada. Variations exist in the care of neonates with NE treated with TH in NICUs across Canada. This paper Identifies areas of variation that are not discussed in detail in the national guidelines and will help to set up quality improvement initiatives. Elucidating the variation in care practices calls for the creation and implementation of a national, consensus-based care bundle, with the objective to improve the outcomes of these critically ill neonates.
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Nakhleh-Philippe P, Zores C, Stern-Delfils A, Escande B, Astruc D, Severac F, Kuhn P. Adequacy of sedation analgesia to support the comfort of neonates undergoing therapeutic hypothermia and its impact on short-term neonatal outcomes. Front Pediatr 2023; 11:1057724. [PMID: 36969279 PMCID: PMC10034099 DOI: 10.3389/fped.2023.1057724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/13/2023] [Indexed: 03/29/2023] Open
Abstract
Objectives We aimed to evaluate (1) whether sedation analgesia (SA) used during therapeutic hypothermia (TH) was efficient to support the wellbeing of neonates with hypoxic-ischemic encephalopathy, (2) the SA level and its adjustment to clinical pain scores, and (3) the impact of inadequate SA on short-term neonatal outcomes evaluated at discharge. Methods This was an observational retrospective study performed between 2011 and 2018 in two level III centers in Alsace, France. We analyzed the wellbeing of infants by using the COMFORT-Behavior (COMFORT-B) clinical score and SA level during TH, according to which we classified infants into four groups: those with excess SA, adequate SA, lack of SA, and variability of SA. We analyzed the variations in doses of SA and their justification. We also determined the impact of inadequate SA on neonatal outcomes at discharge by multivariate analyses with multinomial regression, with adequate SA as the reference. Results A total of 110 patients were included, 89 from Strasbourg university hospital and 21 from Mulhouse hospital. The COMFORT-B score was assessed 95.5% of the time. Lack of SA was mainly found on the first day of TH (15/110, 14%). In all, 62 of 110 (57%) infants were in excess of SA over the entire duration of TH. Most dose variations were related to clinical pain scores. Inadequate SA was associated with negative short-term consequences. Infants with excess of SA had a longer duration of mechanical ventilation [mean ratio 1.46, 95% confidence interval (CI), 1.13-1.89, p = 0.005] and higher incidence of abnormal neurological examination at discharge (odds ratio 2.61, 95% CI, 1.10-6.18, p = 0.029) than infants with adequate SA. Discussion Adequate SA was not easy to achieve during TH. Close and regular monitoring of SA level may help achieve adequate SA. Excess of SA can be harmful for newborns with hypoxic-ischemic encephalopathy who are undergoing TH.
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Affiliation(s)
- Pauline Nakhleh-Philippe
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Department of Neonatology, Hospital of Mulhouse, Mulhouse, France
| | - Claire Zores
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
| | | | - Benoît Escande
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - Dominique Astruc
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - François Severac
- Department of Public Health and Epidemiology, University Hospital of Strasbourg, Strasbourg, France
| | - Pierre Kuhn
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
- Neonatal Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Correspondence: Kuhn Pierre
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Luchette M, LaRovere K, Au CC, Tasker RC, Akhondi-Asl A. Pharmacokinetic Modeling of Optimized Midazolam and Pentobarbital Dosing Used in Treatment Protocols of Refractory Status Epilepticus. Pediatr Crit Care Med 2023; 24:51-55. [PMID: 36394369 DOI: 10.1097/pcc.0000000000003106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To model bolus dosing, infusion rate, and weaning rate on theoretical serum concentration of midazolam and pentobarbital used in the treatment of refractory status epilepticus (RSE). DESIGN One- and two-compartment in silico pharmacokinetic models of midazolam and pentobarbital. SETTING Not applicable. SUBJECTS Not applicable. INTERVENTIONS We compared the model variables used in midazolam and pentobarbital protocols for standard RSE. MEASUREMENTS AND MAIN RESULTS Standard RSE treatment protocols result in steady-state serum concentrations that are 6.2-9.0-fold higher for the one-compartment model and 2.3-4.7-fold higher for the two-compartment model. In the model, not including bolus doses delays the achievement of serum steady-state concentration by 0.5 and 2.7 hours for midazolam and pentobarbital, respectively. Abrupt discontinuation of these medications reduces modeled medication exposure by 1.1 and 6.4 hours, respectively. CONCLUSIONS Our in silico pharmacokinetic modeling of standard midazolam and pentobarbital dosing protocols for RSE suggests potential variables to optimize in future clinical studies.
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Affiliation(s)
- Matthew Luchette
- Department of Anesthesiology, Critical and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Kerri LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Cheuk C Au
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Robert C Tasker
- Department of Anesthesiology, Critical and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
- Selwyn College, University of Cambridge, Cambridge, United Kingdom
| | - Alireza Akhondi-Asl
- Department of Anesthesiology, Critical and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
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Bäcke P, Bruschettini M, Blomqvist YT, Sibrecht G, Olsson E. Interventions for the Management of Pain and Sedation in Newborns Undergoing Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy: A Systematic Review. Paediatr Drugs 2023; 25:27-41. [PMID: 36481984 PMCID: PMC9810674 DOI: 10.1007/s40272-022-00546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Newborn infants undergoing therapeutic hypothermia (TH) are exposed to multiple painful and stressful procedures. The aim of this systematic review was to assess benefits and harms of pharmacological and non-pharmacological interventions for the management of pain and sedation in newborn infants undergoing TH for hypoxic-ischemic encephalopathy. METHODS We included randomized and observational studies reporting any intervention (either drugs or non-pharmacological interventions) to manage pain and sedation in newborn infants (> 33 weeks' gestational age) undergoing TH. We included any dose, duration and route of administration. We also included any type and duration of non-pharmacological interventions. Our prespecified primary outcomes were analgesia and sedation assessed using validated pain scales in the neonatal population; circulatory instability; mortality to discharge; and neurodevelopmental disability. A systematic literature search was conducted in the PubMed, Embase, CINAHL, Cochrane CENTRAL, Scopus, and Web of Science databases, with no language restrictions. Included studies underwent risk-of-bias assessment (Cochrane risk-of-bias tool and ROBINS-I) and data extraction performed by two authors independently. The plan had been to use effect measures such as mean difference for continuous outcomes and risk ratio for dichotomous outcomes, however the included studies are presented in a narrative synthesis due to their paucity and heterogeneity. RESULTS Ten studies involving 3551 infants were included-one trial and nine observational studies. Most studies examined the use of phenobarbital or other antiepileptic drugs with primary outcomes related to seizure activity. The single trial that was included compared pentoxifylline with placebo. Among the primary outcomes, six studies reported circulatory instability and five reported mortality to discharge without relevant differences; two studies reported on neurodevelopmental disability and one study reported on pain scale. Three studies were ongoing. CONCLUSIONS We found limited evidence to establish the benefits and harms of the interventions for the management of pain and sedation in newborn infants undergoing TH. Long-term outcomes were not reported. Given the very low certainty of evidence-due to imprecision of the estimates, inconsistency and limitations in study design (all nine observational studies with overall serious risk of bias)-for all outcomes, clinical trials are required to determine the most effective interventions in this population. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42020205755.
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Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden ,Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Pediatrics, Lund University, Lund, Sweden ,Cochrane Sweden; Research and Education, Skåne University Hospital, Lund, Sweden
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden ,Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Greta Sibrecht
- Newborns’ Infectious Diseases Department, Poznan University of Medical Sciences, Poznan, Poland
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. .,Faculty of Medicine and Health, School of Health Sciences, Örebro University, S-701 82, Örebro, Sweden.
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13
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Bäcke P, Bruschettini M, Sibrecht G, Thernström Blomqvist Y, Olsson E. Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Cochrane Database Syst Rev 2022; 11:CD015023. [PMID: 36354070 PMCID: PMC9647594 DOI: 10.1002/14651858.cd015023.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Newborn infants affected by hypoxic-ischemic encephalopathy (HIE) undergo therapeutic hypothermia. As this treatment seems to be associated with pain, and intensive and invasive care is needed, pharmacological interventions are often used. Moreover, painful procedures in the newborn period can affect pain responses later in life, impair brain development, and possibly have a long-term negative impact on neurodevelopment and quality of life. OBJECTIVES To determine the effects of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. SEARCH METHODS We searched CENTRAL, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the trial register ISRCTN in August 2021. We also checked the reference lists of relevant articles to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCT), quasi-RCTs and cluster-randomized trials comparing drugs used for the management of pain or sedation, or both, during therapeutic hypothermia: any opioids (e.g. morphine, fentanyl), alpha-2 agonists (e.g. clonidine, dexmedetomidine), N-Methyl-D-aspartate (NMDA) receptor antagonist (e.g. ketamine), other analgesics (e.g. paracetamol), and sedatives (e.g. benzodiazepines such as midazolam) versus another drug, placebo, no intervention, or non-pharmacological interventions. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies identified by the search strategy for inclusion. We planned to use the GRADE approach to assess the certainty of evidence. We planned to assess the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomization, blinding, loss to follow-up, and handling of outcome data). We planned to evaluate treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. MAIN RESULTS: We did not find any completed studies for inclusion. Amongst the four excluded studies, topiramate and atropine were used in two and one trial, respectively; one study used dexmedetomidine and was initially reported in 2019 to be a randomized trial. However, it was an observational study (correction in 2021). We identified one ongoing study comparing dexmedetomidine to morphine. AUTHORS' CONCLUSIONS We found no studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia.
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Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Greta Sibrecht
- Newborns' Infectious Diseases Department, Poznan University of Medical Sciences, Poznan, Poland
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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Xiao J, Shi J, Thompson BR, Smith DE, Zhang T, Zhu HJ. Physiologically-Based Pharmacokinetic Modeling to Predict Methylphenidate Exposure Affected by Interplay Among Carboxylesterase 1 Pharmacogenetics, Drug-Drug Interactions, and Sex. J Pharm Sci 2022; 111:2606-2613. [PMID: 35526575 PMCID: PMC9391289 DOI: 10.1016/j.xphs.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE The pharmacokinetics (PK) of methylphenidate (MPH) differ significantly among individuals. Carboxylesterase 1 (CES1) is the primary enzyme metabolizing MPH, and its function is affected by genetic variants, drug-drug interaction (DDI), and sex. The object of this study is to evaluate CES1 pharmacogenetics as related to MPH metabolism using human liver samples and develop a physiologically-based pharmacokinetic (PBPK) modeling approach to investigate the influence of CES1 genotypes and other factors on MPH PK. METHODS The effect of the CES1 variant G143E (rs71647871) on MPH metabolism was studied utilizing 102 individual human liver S9 (HLS9) fraction samples. PBPK models were developed using the population-based PBPK software PK-Sim® by incorporating the HLS9 incubation data. The established models were applied to simulate MPH PK profiles under various clinical scenarios, including different genotypes, drug-alcohol interactions, and the difference between males and females. RESULTS The HLS9 incubation study showed that subjects heterozygous for the CES1 variant G143E metabolized MPH at a rate of approximately 50% of that in non-carriers. The developed PBPK models successfully predicted the exposure alteration of MPH from the G143E genetic variant, ethanol-MPH DDI, and sex. Importantly, the study suggests that male G143E carriers who are alcohol consumers are at a higher risk of MPH overexposure. CONCLUSION PBPK modeling provides a means for better understanding the mechanisms underlying interindividual variability in MPH PK and PD and could be utilized to develop a safer and more effective MPH pharmacotherapy regimen.
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Affiliation(s)
- Jingcheng Xiao
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Jian Shi
- Alliance Pharma, Inc, Malvern, PA, 19355, United States
| | - Brian R Thompson
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, 48109, United States
| | - David E Smith
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Tao Zhang
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, SUNY Binghamton University, Binghamton, NY, 13902, United States
| | - Hao-Jie Zhu
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, MI, 48109, United States.
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Guidotti I, Lugli L, Ori L, Roversi MF, Casa Muttini ED, Bedetti L, Pugliese M, Cavalleri F, Stefanelli F, Ferrari F, Berardi A. Neonatal seizures treatment based on conventional multichannel EEG monitoring: an overview of therapeutic options. Expert Rev Neurother 2022; 22:623-638. [PMID: 35876114 DOI: 10.1080/14737175.2022.2105698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Seizures are the main neurological emergency during the neonatal period and are mostly acute and focal. The prognosis mainly depends on the underlying etiology. Conventional multichannel video-electroencephalographic (cEEG) monitoring is the gold standard for diagnosis, but treatment remains a challenge. AREAS COVERED : This review, based on PubMed search over the last 4 decades, focuses on the current treatment options for neonatal seizures based on cEEG monitoring. There is still no consensus on seizure therapy, owing to poor scientific evidence. Traditionally, the first-line treatments are phenobarbital and phenytoin, followed by midazolam and lidocaine, but their efficacy is limited. Therefore, current evidence strongly suggests the use of alternative antiseizure medications. Randomized controlled trials of new drugs are ongoing. EXPERT OPINION : Therapy for neonatal seizures should be prompt and tailored, based on semeiology, mirror of the underlying cause, and cEEG features. Further research should focus on antiseizure medications that directly act on the etiopathogenetic mechanism responsible for seizures and are therefore more effective in seizure control.
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Affiliation(s)
- Isotta Guidotti
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Licia Lugli
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Luca Ori
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Maria Federica Roversi
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Elisa Della Casa Muttini
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Luca Bedetti
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Marisa Pugliese
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Francesca Cavalleri
- Division of Neuroradiology, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, Modena, Italy
| | - Francesca Stefanelli
- Department of Medical and Surgical Sciences of the Mothers, Children and Adults, Post Graduate School of Pediatrics, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Ferrari
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Alberto Berardi
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
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Pre- and Postnatal Maturation are Important for Fentanyl Exposure in Preterm and Term Newborns: A Pooled Population Pharmacokinetic Study. Clin Pharmacokinet 2021; 61:401-412. [PMID: 34773609 PMCID: PMC8891207 DOI: 10.1007/s40262-021-01076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Fentanyl is an opioid commonly used to prevent and treat severe pain in neonates; however, its use is off label and mostly based on bodyweight. Given the limited pharmacokinetic information across the entire neonatal age range, we characterized the pharmacokinetics of fentanyl across preterm and term neonates to individualize dosing. METHODS We pooled data from two previous studies on 164 newborns with a median gestational age of 29.0 weeks (range 23.9-42.3), birthweight of 1055 g (range 390-4245), and postnatal age (PNA) of 1 day (range 0-68). In total, 673 plasma samples upon bolus dosing (69 patients; median dose 2.1 μg/kg, median 2 boluses per patient) or continuous infusions (95 patients; median dose 1.1 μg/kg/h for 30 h) with and without boluses were used for population pharmacokinetic modeling in NONMEM® 7.4. RESULTS Clearance in neonates with birthweight of 2000 and 3000 g was 2.8- and 5.0-fold the clearance in a neonate with birthweight of 1000 g, respectively. Fentanyl clearance at PNA of 7, 14, and 21 days was 2.7-fold, 3.8-fold, and 4.6-fold the clearance at 1 day, respectively. Bodyweight-based dosing resulted in large differences in fentanyl concentrations. Depending on PNA and birthweight, fentanyl concentrations increased slowly after the start of therapy for both intermittent boluses and continuous infusion and reached a maximum concentration at 12-48 h. CONCLUSIONS As both prenatal and postnatal maturation are important for fentanyl exposure, we propose a birthweight- and PNA-based dosage regimen. To provide rapid analgesia in the first 24 h of treatment, additional loading doses need to be considered.
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Wang Z, Chen Q, Yu L, Huang Y, Cao H. Anesthesia, Sedation, and Unplanned Extubation of Tracheal Intubation in Children with Severe Pneumonia. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:4802389. [PMID: 34707669 PMCID: PMC8545565 DOI: 10.1155/2021/4802389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
We randomly divided 200 children with severe pneumonia who met the indications for tracheal intubation into 2 groups in this prospective study. One group that received dexmedetomidine for sedation was recorded as the dexmedetomidine group (n = 100), and the group that received midazolam for sedation was recorded as the midazolam group (n = 100). We compared the anesthesia sedation scores, time to fall asleep, time to wake up from anesthesia, related hemodynamic parameters, and adverse reactions between the two groups of children. The failure mode and effect analysis method (FMEA) was also used to investigate the causes of unplanned extubation (UEX) of tracheal intubation in 32 children with severe pneumonia. Our conclusion is as follows: (1) Compared with midazolam, the comprehensive effect of dexmedetomidine on children with severe pneumonia undergoing tracheal intubation for anesthesia and sedation is better, it can effectively shorten the anesthesia induction time and the recovery time after stopping the drug, and there are few adverse reactions, which is worthy of application and promotion. (2) UEX is an important risk factor in the monitoring and nursing of children with severe pneumonia tracheal intubation, and the nursing method of PDCA cycle management is particularly important for them.
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Affiliation(s)
- Zengchun Wang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350005, China
- Fujian Branch of Shanghai Children's Medical Center, Fujian Children's Hospital, Fuzhou, Fujian 350014, China
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350005, China
- Fujian Branch of Shanghai Children's Medical Center, Fujian Children's Hospital, Fuzhou, Fujian 350014, China
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
| | - Lingshan Yu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350005, China
- Fujian Branch of Shanghai Children's Medical Center, Fujian Children's Hospital, Fuzhou, Fujian 350014, China
| | - Yu Huang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350005, China
- Fujian Branch of Shanghai Children's Medical Center, Fujian Children's Hospital, Fuzhou, Fujian 350014, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350005, China
- Fujian Branch of Shanghai Children's Medical Center, Fujian Children's Hospital, Fuzhou, Fujian 350014, China
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18
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Karaźniewicz-Łada M, Główka AK, Mikulska AA, Główka FK. Pharmacokinetic Drug-Drug Interactions among Antiepileptic Drugs, Including CBD, Drugs Used to Treat COVID-19 and Nutrients. Int J Mol Sci 2021; 22:ijms22179582. [PMID: 34502487 PMCID: PMC8431452 DOI: 10.3390/ijms22179582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 12/22/2022] Open
Abstract
Anti-epileptic drugs (AEDs) are an important group of drugs of several generations, ranging from the oldest phenobarbital (1912) to the most recent cenobamate (2019). Cannabidiol (CBD) is increasingly used to treat epilepsy. The outbreak of the SARS-CoV-2 pandemic in 2019 created new challenges in the effective treatment of epilepsy in COVID-19 patients. The purpose of this review is to present data from the last few years on drug–drug interactions among of AEDs, as well as AEDs with other drugs, nutrients and food. Literature data was collected mainly in PubMed, as well as google base. The most important pharmacokinetic parameters of the chosen 29 AEDs, mechanism of action and clinical application, as well as their biotransformation, are presented. We pay a special attention to the new potential interactions of the applied first-generation AEDs (carbamazepine, oxcarbazepine, phenytoin, phenobarbital and primidone), on decreased concentration of some medications (atazanavir and remdesivir), or their compositions (darunavir/cobicistat and lopinavir/ritonavir) used in the treatment of COVID-19 patients. CBD interactions with AEDs are clearly defined. In addition, nutrients, as well as diet, cause changes in pharmacokinetics of some AEDs. The understanding of the pharmacokinetic interactions of the AEDs seems to be important in effective management of epilepsy.
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Affiliation(s)
- Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 60-781 Poznań, Poland; (M.K.-Ł.); (A.A.M.)
| | - Anna K. Główka
- Department of Bromatology, Poznan University of Medical Sciences, 60-354 Poznań, Poland;
| | - Aniceta A. Mikulska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 60-781 Poznań, Poland; (M.K.-Ł.); (A.A.M.)
| | - Franciszek K. Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 60-781 Poznań, Poland; (M.K.-Ł.); (A.A.M.)
- Correspondence: ; Tel.: +48-(0)61-854-64-37
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19
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DeLaGarza-Pineda O, Mailo JA, Boylan G, Chau V, Glass HC, Mathur AM, Shellhaas RA, Soul JS, Wusthoff CJ, Chang T. Management of seizures in neonates with neonatal encephalopathy treated with hypothermia. Semin Fetal Neonatal Med 2021; 26:101279. [PMID: 34563467 DOI: 10.1016/j.siny.2021.101279] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Neonatal encephalopathy (NE) is the most common etiology of acute neonatal seizures - about half of neonates treated with therapeutic hypothermia for NE have EEG-confirmed seizures. These seizures are best identified with continuous EEG monitoring, as clinical diagnosis leads to under-diagnosis of subclinical seizures and over-treatment of events that are not seizures. High seizure burden, especially status epilepticus, is thought to augment brain injury. Treatment, therefore, is aimed at minimizing seizure burden. Phenobarbital remains the mainstay of treatment, as it is more effective than levetiracetam and easier to administer than fosphenytoin. Emerging evidence suggests that, for many neonates, it is safe to discontinue the phenobarbital after acute seizures resolve and prior to hospital discharge.
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Affiliation(s)
- Oscar DeLaGarza-Pineda
- Department of Neurology, University Hospital "Dr. Jose E. Gonzalez", Monterrey, Nuevo León, Mexico.
| | - Janette A Mailo
- Neurology & Pediatrics, Stollery Children's Hospital and Glenrose Rehabilitation Hospital University of Alberta, Alberta, Canada.
| | - Geraldine Boylan
- Department of Pediatrics & Child Health University College Cork, Cork, Ireland.
| | - Vann Chau
- Division of Neurology, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA, Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Amit M Mathur
- Division of Neonatal Perinatal Medicine, Saint Louis University School of Medicine, SSM-Health Cardinal Glennon Children's Hospital, Saint Louis, MO, USA.
| | - Renée A Shellhaas
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
| | - Janet S Soul
- Neurology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.
| | - Courtney J Wusthoff
- Division of Child Neurology, Division of Pediatrics-Neonatal and Developmental Medicine Stanford Children's Health, Palo Alto, CA, USA.
| | - Taeun Chang
- Neurology & Pediatrics, George Washington University School of Medicine & Health Sciences, Children's National Hospital, Washington, DC, USA.
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20
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Bäcke P, Bruschettini M, Sibrecht G, Thernström Blomqvist Y, Olsson E. Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Hippokratia 2021. [DOI: 10.1002/14651858.cd015023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit; University Hospital; Uppsala Sweden
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics; Lund University, Skåne University Hospital; Lund Sweden
- Cochrane Sweden; Lund University, Skåne University Hospital; Lund Sweden
| | - Greta Sibrecht
- Newborns' Infectious Diseases Department; Poznan University of Medical Sciences; Poznan Poland
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit; University Hospital; Uppsala Sweden
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health; Örebro University; Örebro Sweden
- Faculty of Medicine and Health, School of Health Sciences; Örebro University; Örebro Sweden
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21
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What is the Best Predictor of Phenobarbital Pharmacokinetics to Use for Initial Dosing in Neonates? Pharmaceutics 2021; 13:pharmaceutics13030301. [PMID: 33668911 PMCID: PMC7996486 DOI: 10.3390/pharmaceutics13030301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 11/17/2022] Open
Abstract
Phenobarbital is a first-line treatment of various seizure types in newborns. Dosage individualization maximizing the proportion of patients with drug levels in therapeutic range or sufficient treatment response is still challenging. The aim of this review was to summarize the available evidence on phenobarbital pharmacokinetics in neonates and to identify its possible covariates suitable for individualization of initial drug dosing. Several covariates have been considered: body weight and height, body surface area, gestational and postnatal age, laboratory parameters of renal and hepatic functions, asphyxia, therapeutic hypothermia, extracorporeal membrane oxygenation (ECMO), drug interactions, and genetic polymorphisms. The most frequently studied and well-founded covariate for the estimation of phenobarbital dosing is actual body weight. Loading dose of 15-20 mg/kg followed by a maintenance dose of 3-5 mg/kg/day seems to be accurate. However, the evidence for the other covariates with respect to dosing individualization is not sufficient. Doses at the lower limit of suggested range should be preferred in patients with severe asphyxia, while the upper limit of the range should be targeted in neonates receiving ECMO support.
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22
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Ayuso M, Buyssens L, Stroe M, Valenzuela A, Allegaert K, Smits A, Annaert P, Mulder A, Carpentier S, Van Ginneken C, Van Cruchten S. The Neonatal and Juvenile Pig in Pediatric Drug Discovery and Development. Pharmaceutics 2020; 13:44. [PMID: 33396805 PMCID: PMC7823749 DOI: 10.3390/pharmaceutics13010044] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/22/2020] [Accepted: 12/22/2020] [Indexed: 02/06/2023] Open
Abstract
Pharmacotherapy in pediatric patients is challenging in view of the maturation of organ systems and processes that affect pharmacokinetics and pharmacodynamics. Especially for the youngest age groups and for pediatric-only indications, neonatal and juvenile animal models can be useful to assess drug safety and to better understand the mechanisms of diseases or conditions. In this respect, the use of neonatal and juvenile pigs in the field of pediatric drug discovery and development is promising, although still limited at this point. This review summarizes the comparative postnatal development of pigs and humans and discusses the advantages of the juvenile pig in view of developmental pharmacology, pediatric diseases, drug discovery and drug safety testing. Furthermore, limitations and unexplored aspects of this large animal model are covered. At this point in time, the potential of the neonatal and juvenile pig as nonclinical safety models for pediatric drug development is underexplored.
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Affiliation(s)
- Miriam Ayuso
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Laura Buyssens
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Marina Stroe
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Allan Valenzuela
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Karel Allegaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (K.A.); (P.A.)
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Department of Hospital Pharmacy, Erasmus MC Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Neonatal Intensive Care Unit, University Hospitals UZ Leuven, 3000 Leuven, Belgium
| | - Pieter Annaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (K.A.); (P.A.)
| | - Antonius Mulder
- Department of Neonatology, University Hospital Antwerp, 2650 Edegem, Belgium;
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, 2610 Wilrijk, Belgium
| | | | - Chris Van Ginneken
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Steven Van Cruchten
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
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23
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Favié LMA, de Haan TR, Bijleveld YA, Rademaker CMA, Egberts TCG, Nuytemans DHGM, Mathôt RAA, Groenendaal F, Huitema ADR. Prediction of Drug Exposure in Critically Ill Encephalopathic Neonates Treated With Therapeutic Hypothermia Based on a Pooled Population Pharmacokinetic Analysis of Seven Drugs and Five Metabolites. Clin Pharmacol Ther 2020; 108:1098-1106. [PMID: 32463940 PMCID: PMC7689752 DOI: 10.1002/cpt.1917] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/19/2020] [Indexed: 12/16/2022]
Abstract
Drug dosing in encephalopathic neonates treated with therapeutic hypothermia is challenging; exposure is dependent on body size and maturation but can also be influenced by factors related to disease and treatment. A better understanding of underlying pharmacokinetic principles is essential to guide drug dosing in this population. The prospective multicenter cohort study PharmaCool was designed to investigate the pharmacokinetics of commonly used drugs in neonatal encephalopathy. In the present study, all data obtained in the PharmaCool study were combined to study the structural system specific effects of body size, maturation, recovery of organ function, and temperature on drug clearance using nonlinear mixed effects modeling. Data collected during the first 5 days of life from 192 neonates treated with therapeutic hypothermia were included. An integrated population pharmacokinetic model of seven drugs (morphine, midazolam, lidocaine, phenobarbital, amoxicillin, gentamicin, and benzylpenicillin) and five metabolites (morphine-3-glucuronide, morphine-6-glucuronide, 1-hydroxymidazolam, hydroxymidazolam glucuronide, and monoethylglycylxylidide) was successfully developed based on previously developed models for the individual drugs. For all compounds, body size was related to clearance using allometric relationships and maturation was described with gestational age in a fixed sigmoidal Hill equation. Organ recovery after birth was incorporated using postnatal age. Clearance increased by 1.23%/hours of life (95% confidence interval (CI) 1.03-1.43) and by 0.54%/hours of life (95% CI 0.371-0.750) for high and intermediate clearance compounds, respectively. Therapeutic hypothermia reduced clearance of intermediate clearance compounds only, by 6.83%/°C (95% CI 5.16%/°C-8.34%/°C). This integrated model can be used to facilitate drug dosing and future pharmacokinetic studies in this population.
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Affiliation(s)
- Laurent M A Favié
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Timo R de Haan
- Department of Neonatology, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Yuma A Bijleveld
- Department of Pharmacy, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Carin M A Rademaker
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Toine C G Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Debbie H G M Nuytemans
- Clinical Research Coordinator PharmaCool Study, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Pharmacy, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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24
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Lutz IC, Allegaert K, de Hoon JN, Marynissen H. Pharmacokinetics during therapeutic hypothermia for neonatal hypoxic ischaemic encephalopathy: a literature review. BMJ Paediatr Open 2020; 4:e000685. [PMID: 32577535 PMCID: PMC7299043 DOI: 10.1136/bmjpo-2020-000685] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Neonatal hypoxic ischaemic encephalopathy due to perinatal asphyxia, can result in severe neurodevelopmental disability or mortality. Hypothermia is at present the only proven neuroprotective intervention. During hypothermia, the neonate may need a variety of drugs with their specific pharmacokinetic profile. The aim of this paper is to determine the effect that hypothermia for neonates suffering from hypoxic ischaemic encephalopathy has on the pharmacokinetics and to what extent dosing regimens need adjustments. METHOD A systematic search was performed on PubMed, Embase and Cochrane Library of literature (2000-2020) using a combination of the following search terms: therapeutic hypothermia, neonate, hypoxic ischemic encephalopathy and pharmacokinetics. Titles and abstracts were screened, and inclusion/exclusion criteria were applied. Finally, relevant full texts were read, and secondary inclusion was applied on the identified articles. RESULTS A total of 380 articles were retrieved, and 34 articles included after application of inclusion/exclusion criteria and duplicate removal, two additional papers were included as suggested by the reviewers. Twelve out of 36 studies on 15 compounds demonstrated a significant decrease in clearance, be it that the extent differs between routes of elimination and compounds, most pronounced for renal elimination (phenobarbital no difference, midazolam metabolite -21%, lidocaine -24%; morphine -21% to -47%, gentamicin -25% to -35%, amikacin -40%) during hypothermia. The data as retrieved in literature were subsequent compared with the dosing regimen as stated in the Dutch paediatric formulary. CONCLUSION Depending on the drug-specific disposition characteristics, therapeutic hypothermia in neonates with hypoxic ischaemic encephalopathy affects pharmacokinetics.
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Affiliation(s)
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Intensive Care and Pediatric Surgery, Erasmus MC Sophia, Rotterdam, The Netherlands
| | - Jan N de Hoon
- Department of Pharmaceutical and Pharmacological Sciences, Center for Clinical Pharmacology, KU Leuven, Leuven, Belgium
| | - Heleen Marynissen
- Department of Pharmaceutical and Pharmacological Sciences, Center for Clinical Pharmacology, KU Leuven, Leuven, Belgium
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25
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Smits A, Annaert P, Van Cruchten S, Allegaert K. A Physiology-Based Pharmacokinetic Framework to Support Drug Development and Dose Precision During Therapeutic Hypothermia in Neonates. Front Pharmacol 2020; 11:587. [PMID: 32477113 PMCID: PMC7237643 DOI: 10.3389/fphar.2020.00587] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/16/2020] [Indexed: 12/21/2022] Open
Abstract
Therapeutic hypothermia (TH) is standard treatment for neonates (≥36 weeks) with perinatal asphyxia (PA) and hypoxic-ischemic encephalopathy. TH reduces mortality and neurodevelopmental disability due to reduced metabolic rate and decreased neuronal apoptosis. Since both hypothermia and PA influence physiology, they are expected to alter pharmacokinetics (PK). Tools for personalized dosing in this setting are lacking. A neonatal hypothermia physiology-based PK (PBPK) framework would enable precision dosing in the clinic. In this literature review, the stepwise approach, benefits and challenges to develop such a PBPK framework are covered. It hereby contributes to explore the impact of non-maturational PK covariates. First, the current evidence as well as knowledge gaps on the impact of PA and TH on drug absorption, distribution, metabolism and excretion in neonates is summarized. While reduced renal drug elimination is well-documented in neonates with PA undergoing hypothermia, knowledge of the impact on drug metabolism is limited. Second, a multidisciplinary approach to develop a neonatal hypothermia PBPK framework is presented. Insights on the effect of hypothermia on hepatic drug elimination can partly be generated from in vitro (human/animal) profiling of hepatic drug metabolizing enzymes and transporters. Also, endogenous biomarkers may be evaluated as surrogate for metabolic activity. To distinguish the impact of PA versus hypothermia on drug metabolism, in vivo neonatal animal data are needed. The conventional pig is a well-established model for PA and the neonatal Göttingen minipig should be further explored for PA under hypothermia conditions, as it is the most commonly used pig strain in nonclinical drug development. Finally, a strategy is proposed for establishing and fine-tuning compound-specific PBPK models for this application. Besides improvement of clinical exposure predictions of drugs used during hypothermia, the developed PBPK models can be applied in drug development. Add-on pharmacotherapies to further improve outcome in neonates undergoing hypothermia are under investigation, all in need for dosing guidance. Furthermore, the hypothermia PBPK framework can be used to develop temperature-driven PBPK models for other populations or indications. The applicability of the proposed workflow and the challenges in the development of the PBPK framework are illustrated for midazolam as model drug.
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Affiliation(s)
- Anne Smits
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Steven Van Cruchten
- Applied Veterinary Morphology, Department of Veterinary Sciences, University of Antwerp, Wilrijk, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Clinical Pharmacy, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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