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Deveci MF, Kaya H, Yurttutan S, Alagoz M, Gokce IK, Karakurt C, Gullu UU, Oncul M, Ozdemir R. Combined (dual) drug therapy for the treatment of patent ductus arteriosus: last approach prior to ligation. Cardiol Young 2023; 33:1312-1315. [PMID: 36472120 DOI: 10.1017/s1047951122003699] [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] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We aimed to evaluate the efficacy of combined (ibuprofen+paracetamol) medical therapy in cases of persistent haemodynamically significant patent ductus arteriosus that are resistant to standard medical monotherapy (ibuprofen and/or paracetamol) in this retrospective multi-centre study. METHODS The combined therapy included the administration of 15mg/kg/dose of paracetamol every 6 h for 3 days and ibuprofen at an initial dose of 10mg/kg/dose followed by 5 mg/kg/dose every 24 h. After 2 days following the administration of the last dose, the researchers evaluated the efficacy of combined treatment by conducting an echocardiographic examination. RESULTS Of all 42 patients who received combined therapy, 37 (88.1%) patients exhibited closure of the haemodynamically significant patent ductus arteriosus without requiring surgical ligation. Patients who did not respond to combined therapy had a higher mean birth weight and gestational age compared to those who responded (p < 0.05). CONCLUSION The researchers believe the success of ibuprofen and paracetamol in haemodynamically significant patent ductus arteriosus treatment may be due to their synergistic efficacy and inhibition of the prostaglandin synthesis pathway through different enzymes. The results of our retrospective trial suggest that combination therapy with paracetamol and ibuprofen can be attempted when monotherapy is unsuccessful in treating haemodynamically significant patent ductus arteriosus, especially in centres without a surgical department.
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Affiliation(s)
- Mehmet F Deveci
- Division of Neonatology, Department of Pediatrics, Inonu University School of Medicine, Malatya, Turkey
| | - Huseyin Kaya
- Division of Neonatology, Department of Pediatrics, Inonu University School of Medicine, Malatya, Turkey
| | - Sadik Yurttutan
- Division of Neonatology, Department of Pediatrics, KSU University School of Medicine, Kahramanmaras, Turkey
| | - Meral Alagoz
- Division of Neonatology, Department of Pediatrics, Inonu University School of Medicine, Malatya, Turkey
| | - Ismail K Gokce
- Division of Neonatology, Department of Pediatrics, Inonu University School of Medicine, Malatya, Turkey
| | - Cemsit Karakurt
- Division of Cardiology, Department of Pediatrics, Inonu University School of Medicine, Malatya, Turkey
| | - Ufuk U Gullu
- Division of Cardiology, Department of Pediatrics, KSU University School of Medicine, Kahramanmaras, Turkey
| | - Mehmet Oncul
- Division of Cardiology, Department of Pediatrics, Inonu University School of Medicine, Malatya, Turkey
| | - Ramazan Ozdemir
- Division of Neonatology, Department of Pediatrics, Inonu University School of Medicine, Malatya, Turkey
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Namba F, Honda M, Sakatani S, Motojima Y, Kikuchi K, Sako M, Ogawa K, Mikami M, Kawada K, Fukuoka N, Ueda K. iPAPP: study protocol for a multicentre randomised controlled trial comparing safety and efficacy of intravenous paracetamol and indomethacin for the treatment of patent ductus arteriosus in preterm infants. BMJ Open 2023; 13:e069314. [PMID: 36958775 PMCID: PMC10039996 DOI: 10.1136/bmjopen-2022-069314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
INTRODUCTION Patent ductus arteriosus (PDA) causes severe morbidity in premature infants. Although the use of indomethacin is the standard therapy for PDA, it is sometimes not applicable because of its adverse effects, such as renal and platelet dysfunctions. Paracetamol has emerged as an alternative to indomethacin owing to its excellent safety profile in infants. Of the recently reported case series and clinical trials on the use of paracetamol for PDA, there are few reports in Japan on paracetamol use in preterm infants. Furthermore, indications for the use of paracetamol for PDA have not been approved for use in PDA. While the safety of intravenous paracetamol therapy in case series of preterm infants treated for haemodynamically significant PDA (hsPDA) has been reported, studies which were conducted to compare paracetamol to indomethacin are limited. We, therefore, intend to investigate the hypothesis that intravenous administration of paracetamol has superior safety over indomethacin. METHODS AND ANALYSIS Multicentre open-label randomised controlled trial for intravenous administration of paracetamol for PDA in preterm infants. The inclusion criteria are (1) hsPDA, (2) gestational age from 24 to 34 weeks and birth weight (BW) from 500 to 2000 g, (3) enrolment between 24 hours and 7 days from birth and (4) obtaining parental consent. The primary outcome is renal dysfunction within 48 hours from the last dose of the study drug. Enrolled patients fulfilling all the inclusion criteria are randomly allocated to either intravenous paracetamol or intravenous indomethacin. This trial requires 110 patients. ETHICS AND DISSEMINATION The clinical trial would follow Japan's Clinical Trials Act. The trial protocol was approved by the Clinical Research Review Board of Saitama Medical University (approval number: 222001). A written informed consent would be obtained from one of the parents. The results are expected to be published in a scientific journal. TRIAL REGISTRATION NUMBER jRCTs031220386. PROTOCOL VERSION 31 March 2022, version 1.0.
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Affiliation(s)
- Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Masakazu Honda
- Department of Pediatrics, Saitama Medical University Hospital, Iruma, Saitama, Japan
| | - Shun Sakatani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
- Department of Neonatology, Tokyo Metropolitan Children's Medical, Fuchu, Tokyo, Japan
| | - Yukiko Motojima
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Kayoko Kikuchi
- Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Mayumi Sako
- Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Kunio Ogawa
- Department of Health Policy, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Masashi Mikami
- Biostatistics Unit, Department of Data Science, Clinical Research Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Kou Kawada
- Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Osaka, Japan
| | - Noriyasu Fukuoka
- Laboratory of Hospital Pharmacy, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Keiko Ueda
- European Clinical Research Infrastructure Network, Paris, France
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Vakiliamini M, Daryoushi H, Babai H, Chegene Lorestani R, Rostamian M, Akya A, Habibi R, Ghadiri K. Comparison of Therapeutic Effect and Safety of Oral and Rectal Use of Acetaminophen on Patent Ductus Arteriosus in Preterm Infants: Clinical Randomized Trial. Glob Pediatr Health 2023; 10:2333794X231152116. [PMID: 36733954 PMCID: PMC9887655 DOI: 10.1177/2333794x231152116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/03/2023] [Indexed: 01/31/2023] Open
Abstract
The prevalence of patent ductus arteriosus (PDA) in preterm infants is high. There is little information about the therapeutic effect and safety of rectal acetaminophen in the treatment of PDA. We aimed to compare the therapeutic effect and safety of oral and rectal acetaminophen on PDA in preterm infants. This study was a single-blind randomized clinical trial using 40 preterm infants. The cases were hospitalized in the neonatal intensive care unit of Mohammad Kermanshahi and Imam Reza hospitals of Kermanshah. Subjects were randomly divided into 2 groups, the first group was treated with oral acetaminophen and the second group was treated with rectal acetaminophen. The presence of PDA and response to treatment was assessed based on pre- and post-treatment echocardiographic criteria. The likelihood of complications or prohibition of acetaminophen use was assessed with paraclinical tests before and after treatment. The neonates were in the age range of 30 to 35 weeks. Twenty-one cases (52.5%) were boys and 19 cases (47.5%) were girls. Two cases in the oral-acetaminophen group and 1 case in the rectal-acetaminophen group needed the second round of treatment. There was no difference between the success of treatment and the type of treatment. The study showed that there was no difference between PDA treatment of preterm infants with oral and rectal acetaminophen. Also, no side effects were observed in treatment with any of the treatments. Therefore, it could be suggested that in infants who are intolerant to oral acetaminophen, the rectal form can be used.
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Affiliation(s)
- Mazyar Vakiliamini
- Department of Pediatrics, Clinical
Research Development Center, Imam Khomaini and Mohammad Kermanshahi Hospitals,
Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Hooman Daryoushi
- Department of Pediatrics, Clinical
Research Development Center, Imam Khomaini and Mohammad Kermanshahi Hospitals,
Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Homa Babai
- Department of Pediatrics, Clinical
Research Development Center, Imam Reza Hospital, Kermanshah University of Medical
Sciences, Kermanshah, Iran
| | - Roya Chegene Lorestani
- Infectious Diseases Research Center,
Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mosayeb Rostamian
- Infectious Diseases Research Center,
Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alisha Akya
- Infectious Diseases Research Center,
Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Habibi
- Department of Pediatrics, Clinical
Research Development Center, Imam Khomaini and Mohammad Kermanshahi Hospitals,
Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Keyghobad Ghadiri
- Infectious Diseases Research Center,
Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran,Keyghobad Ghadiri, Infectious Diseases
Research Center, Kermanshah University of Medical Sciences Kermanshah, P.O. Box:
6714415333, Kermanshah, Iran.
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Jasani B, Mitra S, Shah PS. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants. Cochrane Database Syst Rev 2022; 12:CD010061. [PMID: 36519620 DOI: 10.1002/14651858.cd010061.pub5] [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: 12/23/2022]
Abstract
BACKGROUND The different management strategies for patent ductus arteriosus (PDA) in preterm infants are expectant management, surgery, or medical treatment with non-selective cyclo-oxygenase inhibitors. Randomized controlled trials (RCTs) have suggested that paracetamol may be an effective and safe agent for the closure of a PDA. OBJECTIVES To determine the efficacy and safety of paracetamol as monotherapy or as part of combination therapy via any route of administration, compared with placebo, no intervention, or another prostaglandin inhibitor, for prophylaxis or treatment of an echocardiographically-diagnosed PDA in preterm or low birth weight infants. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and three trials registers on 13 October 2021, and one other database on 1 March 2022. We also checked references and contacted study authors to identify additional studies. SELECTION CRITERIA We included RCTs and quasi-RCTs in which paracetamol (single-agent or combination therapy) was compared to no intervention, placebo, or other agents used for closure of PDA, irrespective of dose, duration, and mode of administration in preterm infants. Two independent authors reviewed the search results and made a final selection of potentially eligible articles through discussion. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of Cochrane Neonatal. We used the GRADE approach to assess the certainty of evidence for the following outcomes: failure of ductal closure after the first course of treatment; all-cause mortality during initial hospital stay; and necrotizing enterocolitis (NEC). MAIN RESULTS For this update, we included 27 studies enrolling 2278 infants. We considered the overall risk of bias in the 27 studies to vary from low to unclear. We identified 24 ongoing studies. Paracetamol versus ibuprofen There was probably little to no difference between paracetamol and ibuprofen for failure of ductal closure after the first course (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.88 to 1.18; 18 studies, 1535 infants; moderate-certainty evidence). There was likely little to no difference between paracetamol and ibuprofen for all-cause mortality during hospital stay (RR 1.09, 95% CI 0.80 to 1.48; 8 studies, 734 infants; moderate-certainty evidence), and for NEC (RR 1.30, 95% CI 0.87 to 1.94; 10 studies, 1015 infants; moderate-certainty evidence). Paracetamol versus indomethacin There was little to no difference between paracetamol and indomethacin for failure of ductal closure after the first course (RR 1.02, 95% CI 0.78 to 1.33; 4 studies, 380 infants; low-certainty evidence). There was little to no difference between paracetamol and indomethacin for all-cause mortality during hospital stay (RR 0.86, 95% CI 0.39 to 1.92; 2 studies, 114 infants; low-certainty evidence). The rate of NEC may be lower in the paracetamol group (3.7%) versus the indomethacin group(9.2%) (RR 0.42, 95% CI 0.19 to 0.96; 4 studies, 384 infants; low-certainty evidence). Prophylactic paracetamol versus placebo/no intervention Prophylactic paracetamol (17%) compared to placebo/no intervention (61%) may reduce failure of ductal closure after one course (RR 0.27, 95% CI 0.18 to 0.42; 3 studies, 240 infants; low-certainty evidence). There was little to no difference between prophylactic paracetamol and placebo/no intervention for all-cause mortality during hospital stay (RR 0.59, 95% CI 0.24 to 1.44; 3 studies, 240 infants; low-certainty evidence). No studies reported on NEC. Early paracetamol treatment versus placebo/no intervention Early paracetamol treatment (28%) compared to placebo/no intervention (79%) may reduce failure of ductal closure after one course when used before 14 days' postnatal age (RR 0.35, 95% CI 0.23 to 0.53; 2 studies, 127 infants; low-certainty evidence). No studies reported on all-cause mortality during hospital stay or NEC. Late paracetamol treatment versus placebo/no intervention There was little to no difference between late paracetamol and placebo for failure of ductal closure after one course of treatment when used at or after 14 days' postnatal age (RR 0.85, 95% CI 0.72 to 1.01; 1 study, 55 infants; low-certainty evidence) or NEC (RR 1.04, 95% CI 0.07 to 15.76; 1 study, 55 infants; low-certainty evidence). No data were reported for all-cause mortality during hospital stay. Paracetamol combined with ibuprofen versus ibuprofen combined with placebo or no intervention There was little to no difference between paracetamol plus ibuprofen compared to ibuprofen plus placebo or no intervention for failure of ductal closure after the first course (RR 0.77, 95% CI 0.43 to 1.36; 2 studies, 111 infants; low-certainty evidence). There was little to no difference between paracetamol plus ibuprofen compared to ibuprofen plus placebo or no intervention for NEC (RR 0.33, 95% CI 0.01 to 7.45; 1 study, 24 infants; low-certainty evidence). No data were reported for all-cause mortality during hospital stay. AUTHORS' CONCLUSIONS: Moderate-certainty evidence suggests that there is probably little or no difference in effectiveness between paracetamol and ibuprofen; low-certainty evidence suggests that there is probably little or no difference in effectiveness between paracetamol and indomethacin; low-certainty evidence suggests that prophylactic paracetamol may be more effective than placebo/no intervention; low-certainty evidence suggests that early paracetamol treatment may be more effective than placebo/no intervention; low-certainty evidence suggests that there is probably little or no difference between late paracetamol treatment and placebo, and probably little or no difference in effectiveness between the combination of paracetamol plus ibuprofen versus ibuprofen alone for the closure of PDA after the first course of treatment. The majority of neonates included in these studies were of moderate preterm gestation. Thus, establishing the efficacy and safety of paracetamol for PDA treatment in extremely low birth weight (ELBW: birth weight < 1000 grams) and extremely low gestational age neonates (ELGANs < 28 weeks' gestation) requires further studies.
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Affiliation(s)
- Bonny Jasani
- Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Souvik Mitra
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, Canada
| | - Prakeshkumar S Shah
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto Mount Sinai Hospital, Toronto, Canada
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Shah SD, Makker K, Zhang M, Harnett S, Aziz KB, Hudak ML. Dual medication therapy (acetaminophen and ibuprofen) for the management of patent ductus arteriosus in preterm infants: a systematic review and meta-analysis. J Perinatol 2022; 42:1654-1661. [PMID: 36008521 DOI: 10.1038/s41372-022-01500-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/04/2022] [Accepted: 08/17/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To examine the efficacy of dual medication therapy (intervention) (DMT: acetaminophen and ibuprofen) vs. single medication therapy (control) (SMT: ibuprofen) for medical management of PDA (outcomes) in preterm infants (population). STUDY DESIGN We systematically searched multiple sources to identify randomized controlled trials (RCT) and non-randomized studies (NRS) that compared DMT to SMT for management of hemodynamically significant PDA. RESULTS We identified two RCTs and four NRS. There were no differences in the rates of successful PDA closure following the first treatment course between DMT and SMT (RR = 1.23 [95% CI 0.89-1.70] for NRS and RR = 1.18 [95% CI 0.66-2.10] for RCTs), nor were there significant differences in secondary outcomes and adverse events including PDA ligation, bronchopulmonary dysplasia, and necrotizing enterocolitis etc. Markers of hepatic/renal function did not change significantly during treatment. CONCLUSION We found no evidence for superiority of DMT over SMT in PDA management.
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Affiliation(s)
- Sanket D Shah
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA.
| | - Kartikeya Makker
- Division of Neonatology, Department of Pediatrics, Johns Hopkins Children's Center, Johns Hopkins University, Baltimore, MD, USA
| | - Mingyu Zhang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Khyzer B Aziz
- Division of Neonatology, Department of Pediatrics, Johns Hopkins Children's Center, Johns Hopkins University, Baltimore, MD, USA
| | - Mark L Hudak
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL, USA
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Oral versus intravenous paracetamol for patent ductus arteriosus closure in preterm infants. Pediatr Res 2022; 92:1146-1152. [PMID: 35087197 DOI: 10.1038/s41390-022-01944-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND To examine whether oral administration of paracetamol as a first-line agent had a greater effect on the closure of a patent ductus arteriosus than the intravenous route. METHODS We performed a retrospective study of preterm infants (<37 weeks of gestation) between 2012 and 2020 treated with oral or intravenous paracetamol as the first line for patent ductus arteriosus (PDA) constriction and compared rates of ductal closure, course duration, cumulative dose, PDA characteristics, and serum levels. RESULTS Over the study period, 80 preterm infants received paracetamol, of which 50 received paracetamol as first-line treatment to augment constriction of the PDA. Closure rate was higher in the oral group (n = 15/19, 79%) compared to the intravenous group (n = 8/20, 40%, p < 0.01), and remained significant after adjusting for gestational age, length of treatment, and postnatal age (OR 0.14, 95% CI 0.03-0.67, p = 0.014, RR 0.51, 95% CI 0.28-0.91). Eleven preterm infants received a combination of both oral and intravenous paracetamol with a closure rate of 45% (n = 5). CONCLUSIONS Oral administration of paracetamol as a first-line agent is more efficacious to constrict the PDA than the intravenous route, irrespective of gestational age or course duration. IMPACT Our retrospective study comparing the use of oral versus intravenous paracetamol as the first line for patent ductus arteriosus (PDA) constriction in preterm infants demonstrates that oral administration of paracetamol is more efficacious to constrict the PDA than the intravenous route, irrespective of gestational age or course duration. To our knowledge, this is the first published study (prospective or retrospective) to compare the efficacy of oral versus intravenous paracetamol as a first-line treatment for PDA closure in preterm infants. Our finding may improve the rate of PDA closure when paracetamol is used as a first-line agent.
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Shah SD, Makker K, Nandula P, Smotherman C, Kropf A, Hudak ML. Effectiveness of Dual Medication Therapy (Oral Acetaminophen and Oral Ibuprofen) for the Management of Patent Ductus Arteriosus in Extremely Premature Infants: A Feasibility Trial. Am J Perinatol 2022; 39:1326-1333. [PMID: 33454945 DOI: 10.1055/s-0040-1722329] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The study aimed to evaluate the efficacy of dual medication therapy (DMT) with oral acetaminophen and oral ibuprofen for the closure of a hemodynamically significant patent ductus arteriosus (hsPDA). STUDY DESIGN In a prospective case-control cohort study (July 2017-May 2019), infants <29 weeks' gestational age and birth weight <1,000 g at ≤14 postnatal days with hsPDA and ratio of the smallest ductal diameter to the ostium of the left pulmonary artery diameter >0.5 were eligible. Infants received 10 mg/kg oral ibuprofen followed by two additional doses of 5 mg/kg at 24 and 48 hours after the initial ibuprofen dose and concomitant treatment with 15 mg/kg oral acetaminophen every 6 hours for 3 days (12 doses). Success of PDA treatment was defined as a small or absent PDA as ascertained by echocardiographic measurements. The p-values of comparisons were adjusted for multiple comparisons to preserve an error rate of 5%. RESULTS Overall, 20 infants received oral DMT and 11 infants received intravenous single medication therapy (SMT) with ibuprofen. The rates of successful PDA treatment following the first treatment in DMT and SMT groups were not statistically different (11/20 [55%] vs. 4/11 [36%], p = 0.46). However, DMT significantly decreased PDA size (mean difference = 0.54 mm, 95% confidence interval [CI]: 0.21-0.96, adjusted p-value = 0.0002) and PDA/LPA ratio (mean difference = 0.27, 95% CI: 0.10-0.47, adjusted p-value = 0.0004). We observed no evidence of hematologic, hepatic, or renal impairment. CONCLUSION DMT achieved a greater degree of PDA closure than SMT and did not result in abnormalities in hepatic and renal profile. KEY POINTS · No consensus on optimal medication for PDA treatment is available.. · Dual oral medication therapy (ibuprofen and acetaminophen) could be an effective alternative treatment for PDA.. · Dual oral medication therapy (ibuprofen and acetaminophen) may have a better safety profile than currently approved medications such as intravenous indomethacin and intravenous ibuprofen..
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Affiliation(s)
- Sanket D Shah
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, Jacksonville, Florida
| | - Kartikeya Makker
- Department of Pediatrics, Division of Neonatology, Johns Hopkins Children's Center, John Hopkins University, Baltimore, Maryland
| | - Padma Nandula
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, Jacksonville, Florida
| | - Carmen Smotherman
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
| | - Andrea Kropf
- Department of Pediatrics, Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Mark L Hudak
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, Jacksonville, Florida
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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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Surak A, Jain A, Hyderi A. Different approaches for patent ductus arteriosus in premature infants using acetaminophen. World J Pediatr 2022; 18:243-250. [PMID: 35253098 DOI: 10.1007/s12519-022-00526-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acetaminophen use for pharmacological treatment of hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants is becoming more popular with emerging evidence that it is effective as well as safe alternative for other agents used to close hsPDA. DATA SOURCES We performed a narrative review of literature about pharmacological treatment of PDA using acetaminophen. RESULTS Acetaminophen was used as a prophylaxis, symptomatic, targeted, and a rescue approach. CONCLUSIONS It appears that acetaminophen could be used in different approaches to close the hsPDA. Long-term outcomes of acetaminophen exposure early in life still lack certainty.
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Affiliation(s)
- Aimann Surak
- Northern Alberta Neonatal Program Royal Alexandra Hospital Site NICU, DTC 5027, Stollery Children Hospital, University of Alberta, 10240 Kingsway NW, Edmonton, AB, T5H 3V9, Canada.
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Abbas Hyderi
- Northern Alberta Neonatal Program Royal Alexandra Hospital Site NICU, DTC 5027, Stollery Children Hospital, University of Alberta, 10240 Kingsway NW, Edmonton, AB, T5H 3V9, Canada
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10
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Wright CJ. Acetaminophen and the Developing Lung: Could There Be Lifelong Consequences? J Pediatr 2021; 235:264-276.e1. [PMID: 33617854 PMCID: PMC9810455 DOI: 10.1016/j.jpeds.2021.02.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 01/05/2023]
Affiliation(s)
- Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
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Godin R, Rodriguez JC, Kahn DJ. Oral Versus Intravenous Medications for Treatment of Patent Ductus Arteriosus in Preterm Neonates: A Cost-Saving Initiative. J Pediatr Pharmacol Ther 2021; 26:291-299. [PMID: 33833632 DOI: 10.5863/1551-6776-26.3.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 10/18/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The purpose of the study was to quantify cost savings after promoting oral pharmacotherapy for the treatment of hemodynamically significant patent ductus arteriosus (hsPDA). METHODS This was a retrospective before-and-after time series quality improvement study. Oral ibuprofen and acetaminophen use criteria were developed and recommended, rather than the more costly intravenous equivalents. There were 24-month medication use reports generated for both the pre-criteria (Era-1) and the post-criteria (Era-2) implementation phases to identify neonates prescribed hsPDA medications in order to assess cost differences. RESULTS Era-1 had 190 treatment courses in 110 neonates for a total medication cost of $171,260.70. Era-2 had 210 courses in 109 patients for a total medication cost of $47,461.49, yielding savings of $123,799.21 ($61,899.61 annually) after criteria implementation. The reduction in intravenous ibuprofen use in Era-2 accounted for all the savings. CONCLUSION Preferentially prescribing lower-cost oral medications to treat hsPDA led to significant cost savings.
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12
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Soliman RM, Mostafa FA, Abdelmassih A, Sultan E, Mosallam D. Patent ductus arteriosus in preterm infants; experience of a tertiary referral neonatal intensive care unit: prevalence, complications, and management. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2020. [DOI: 10.1186/s43054-020-00046-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Patent ductus arteriosus poses diagnostic and therapeutic dilemma for clinicians, diagnosis of persistent PDA, and determination of its clinical and hemodynamic significance are challenging. The aim of this study is to determine the prevalence of PDA in preterm infants admitted to our NICU, to report cardiac and respiratory complications of PDA, and to study the management strategies and their subsequent outcomes.
Result
Echocardiography was done for 152 preterm babies admitted to neonatal intensive care unit (NICU) on day 3 of life. Eighty-seven (57.2%) preterms had PDA; 54 (62.1%) non-hemodynamically significant PDA (non-hsPDA), and 33 (37.9%) hemodynamically significant PDA. Hemodynamically significant PDA received medical treatment (paracetamol 15 mg/kg/6 h IV for 3 days). Follow-up echocadiography was done on day 7 of life. Four babies died before echo was done on day 7. Twenty babies (68.9%) achieved closure after 1st paracetamol course. Nine babies received 2nd course paracetamol. Follow-up echo done on day 11 of life showed 4 (13.7%) babies achieved successful medical closure after 2nd paracetamol course; 5 babies failed closure and were assigned for surgical ligation. The group of non-hsPDA showed spontaneous closure after conservative treatment. Pulmonary hemorrhage was significantly higher in hsPDA group. Mortality was higher in hsPDA group than non-hsPDA group.
Conclusion
Echocardiographic evaluation should be done for all preterms suspected clinically of having PDA. We should not expose vulnerable population of preterm infants to medication with known side effects unnecessarily; we should limit medical closure of PDA to hsPDA. Paracetamol offers several important therapeutic advantages options being well tolerated and having more favorable side effects profile.
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13
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Ohlsson A, Shah PS. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants. Cochrane Database Syst Rev 2020; 1:CD010061. [PMID: 31985831 PMCID: PMC6984659 DOI: 10.1002/14651858.cd010061.pub4] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In preterm newborns, the ductus arteriosus frequently fails to close and the infants require medical or surgical closure of the patent ductus arteriosus (PDA). A PDA can be treated surgically; or medically with one of two prostaglandin inhibitors, indomethacin or ibuprofen. Case reports suggest that paracetamol may be an alternative for the closure of a PDA. An association between prenatal or postnatal exposure to paracetamol and later development of autism or autism spectrum disorder has been reported. OBJECTIVES To determine the effectiveness and safety of intravenous or oral paracetamol compared with placebo or no intervention, intravenous indomethacin, intravenous or oral ibuprofen, or with other cyclo-oxygenase inhibitors for treatment of an echocardiographically diagnosed PDA in preterm or low birth weight infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 10), MEDLINE via PubMed (1966 to 6 November 2017), Embase (1980 to 6 November 2017), and CINAHL (1982 to 6 November 2017). We searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCT) and quasi-randomised trials. SELECTION CRITERIA We included RCTs in which paracetamol was compared to no intervention, placebo or other agents used for closure of PDA irrespective of dose, duration and mode of administration in preterm (≤ 34 weeks' postmenstrual age) infants. We both reviewed the search results and made a final selection of potentially eligible articles by discussion. We included studies of both prophylactic and therapeutic use of paracetamol. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of evidence for the following outcomes when data were available: failure of ductal closure after the first course of treatment; neurodevelopmental impairment; all-cause mortality during initial hospital stay (death); gastrointestinal bleed or stools positive for occult blood; and serum levels of creatinine after treatment (µmol/L). MAIN RESULTS We included eight studies that reported on 916 infants. One of these studies compared paracetamol to both ibuprofen and indomethacin. Five studies compared treatment of PDA with paracetamol versus ibuprofen and enrolled 559 infants. There was no significant difference between paracetamol and ibuprofen for failure of ductal closure after the first course of drug administration (typical risk ratio (RR) 0.95, 95% confidence interval (CI) 0.75 to 1.21; typical risk difference (RD) -0.02, 95% CI -0.09 to 0.09); I² = 0% for RR and RD; moderate quality of evidence. Four studies (n = 537) reported on gastrointestinal bleed which was lower in the paracetamol group versus the ibuprofen group (typical RR 0.28, 95% CI 0.12 to 0.69; typical RD -0.06, 95% CI -0.09 to -0.02); I² = 0% for RR and RD; number needed to treat for an additional beneficial outcome (NNTB) 17 (95% CI 11 to 50); moderate quality of evidence. The serum levels of creatinine were lower in the paracetamol group compared with the ibuprofen group in four studies (moderate quality of evidence), as were serum bilirubin levels following treatment in two studies (n = 290). Platelet counts and daily urine output were higher in the paracetamol group compared with the ibuprofen group. One study reported on long-term follow-up to 18 to 24 months of age following treatment with paracetamol versus ibuprofen. There were no significant differences in the neurological outcomes at 18 to 24 months (n = 61); (low quality of evidence). Two studies compared prophylactic administration of paracetamol for a PDA with placebo or no intervention in 80 infants. Paracetamol resulted in a lower rate of failure of ductal closure after 4 to 5 days of treatment compared to placebo or no intervention which was of borderline significance for typical RR 0.49 (95% CI 0.24 to 1.00; P = 0.05); but significant for typical RD -0.21 (95% CI -0.41 to -0.02); I² = 0 % for RR and RD; NNTB 5 (95% CI 2 to 50); (low quality of evidence). Two studies (n = 277) compared paracetamol with indomethacin. There was no significant difference in the failure to close a PDA (typical RR 0.96, 95% CI 0.55 to 1.65; I² = 11%; typical RD -0.01, 95% CI -0.09 to 0.08; I² = 17%) (low quality of evidence). Serum creatinine levels were significantly lower in the paracetamol group compared with the indomethacin group and platelet counts and daily urine output were significantly higher in the paracetamol group. AUTHORS' CONCLUSIONS Moderate-quality evidence according to GRADE suggests that paracetamol is as effective as ibuprofen; low-quality evidence suggests paracetamol to be more effective than placebo or no intervention; and low-quality evidence suggests paracetamol as effective as indomethacin in closing a PDA. There was no difference in neurodevelopmental outcome in children exposed to paracetamol compared to ibuprofen; however the quality of evidence is low and comes from only one study. In view of concerns raised regarding neurodevelopmental outcomes following prenatal and postnatal exposure to paracetamol, long-term follow-up to at least 18 to 24 months' postnatal age must be incorporated in any studies of paracetamol in the newborn population. At least 19 ongoing trials have been registered. Such trials are required before any recommendations for the possible routine use of paracetamol in the newborn population can be made.
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Affiliation(s)
- Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and EvaluationTorontoCanada
| | - Prakeshkumar S Shah
- University of Toronto Mount Sinai HospitalDepartment of Paediatrics and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoONCanadaM5G 1XB
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Schindler T, Smyth J, Bolisetty S, Michalowski J, Lui K. Early PARacetamol (EPAR) trial: a study protocol for a randomised controlled trial of early paracetamol to promote closure of the ductus arteriosus in preterm infants. BMJ Open 2019; 9:e031428. [PMID: 31666270 PMCID: PMC6830666 DOI: 10.1136/bmjopen-2019-031428] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The optimal management of patent ductus arteriosus (PDA) remains contentious. The medications used to treat PDA are often non-steroidal anti-inflammatory drugs, which are associated with a number of unwanted adverse effects. Paracetamol is a medication with an excellent safety profile in infants and has been suggested as a safe alternative medication in situations where other medications have failed or are contraindicated. There are limited data on the use of early, intravenous paracetamol in preterm infants. METHODS AND ANALYSIS This trial aims to address whether early treatment with paracetamol will reduce the number of infants requiring intervention for PDA. This is a randomised, double-blind, placebo-controlled trial in preterm infants <29 weeks' gestation. At 6 hours of life, infants with a ductus arteriosus >0.9 mm will be randomised to receive either (1) intravenous paracetamol at a dose of 15 mg/kg initially, followed by every 6 hours at a dose of 7.5 mg/kg for 5 days; or (2) intravenous 5% dextrose every 6 hours for 5 days. The primary outcome is the need for any intervention for management of PDA up to 5 days. Secondary outcomes include closure of the ductus arteriosus at 5 days, size of the ductus arteriosus, ductal reopening, systemic blood flow, mortality and significant morbidities. The target sample size of 100 infants yields >80% power, at the two-sided 5% level significance, to detect a 50% reduction in the need for intervention assuming that approximately 60% of infants in this study would otherwise have required intervention for PDA. ETHICS AND DISSEMINATION A report on the results of the planned analyses will be prepared. The results of the primary analysis of all end points will be presented at medical conferences and submitted for publication in peer-reviewed journals. Separate manuscripts pertaining to the second aim of the study may be written, and these will also be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ACTRN12616001517460.
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Affiliation(s)
- Tim Schindler
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - John Smyth
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Srinivas Bolisetty
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Joanna Michalowski
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Kei Lui
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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Escobar HA, Meneses-Gaviria G, Revelo-Jurado N, Villa-Rosero JF, Ijají Piamba JE, Burbano-Imbachí A, Cedeño-Burbano AA. Tratamiento farmacológico del conducto arterioso permeable en recién nacidos prematuros. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n2.64146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. Por lo general, el manejo farmacológico del conducto arterioso permeable (CAP) comprende inhibidores no selectivos de la enzima ciclooxigenasa, en especial indometacina e ibuprofeno. En años recientes también se ha sugerido al acetaminofén como alternativa terapéutica.Objetivo. Realizar una revisión narrativa de la literatura acerca del manejo farmacológico del CAP.Materiales y métodos. Se realizó una búsqueda estructurada de la literatura en las bases de datos ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip Database, SciELO y Cochrane Library con los términos “Ductus Arteriosus, patent AND therapeutics”; “Ductus Arteriosus, patent AND indometacin”; “Ductus Arteriosus, Patent AND ibuprofen”, y “Ductus Arteriosus, patent AND acetaminophen”. La búsqueda se hizo en inglés con sus equivalentes en español.Resultados. Se encontraron 69 artículos con información relevante para llevar a cabo la presente revisión.Conclusiones. En neonatos prematuros, la base del tratamiento farmacológico del CAP continúa siendo los inhibidores no selectivos de la ciclooxigenasa, indometacina e ibuprofeno, ambos con perfiles similares de seguridad y eficacia. La evidencia disponible sugiere que el acetaminofén podría constituir una alternativa útil para el manejo, pero resulta insuficiente para realizar recomendaciones definitivas respecto a la eficacia y seguridad de este medicamento.
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Çakır U, Tayman C. The effect of thyroid functions on osteopenia of prematurity in preterm infants. J Pediatr Endocrinol Metab 2019; 32:65-70. [PMID: 30511932 DOI: 10.1515/jpem-2018-0429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/11/2018] [Indexed: 11/15/2022]
Abstract
Background It is known that thyroid hormones have effects on bone development. In particular, the effect of thyroid hormones on osteopenia of prematurity (OOP) has not been examined in preterm infants. Our study aimed to examine the relationship between OOP and congenital hypothyroidism (CH) in preterm infants. Methods Very low birth weight infants (VLBW, <1500 g) were included in the study. Thyroid-stimulating hormone (TSH) and free thyroxine (fT4) levels were measured on postnatal day 5. Serum calcium, phosphorus and alkaline phosphatase (ALP) levels were studied as standard screening parameters for OOP at postnatal week 4. Patients with serum ALP level >700 IU/L were included in the OOP group. We intended to figure out the relationship between OOP and CH in infants. Results In our study, OOP frequency was 14.9% among 543 VLBW infants. There was no statistically significant difference between groups with and without CH (21.7% and 14.8%, respectively) in terms of OOP (p=0.632). Gestational age (GA) was significantly lower in infants with diagnosed OOP (p<0.001, p<0.001, respectively). In addition, the prevalence rates of mothers with preeclampsia, small for gestational age (SGA), respiratory support requirement, late-onset neonatal sepsis (LOS), bronchopulmonary dysplasia (BPD) and full enteral feeding time were found to be higher in the OOP group (p<0.05). Conclusions We found that thyroid hormones had no effect on OOP in preterm infants. Therefore, future randomized controlled studies as well as long-term outcome studies are warranted on this topic.
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Affiliation(s)
- Ufuk Çakır
- Division of Neonatology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Altıntag, Ankara, Turkey
| | - Cuneyt Tayman
- Division of Neonatology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Altıntag, Ankara, Turkey
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17
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Hundscheid T, Onland W, van Overmeire B, Dijk P, van Kaam AHLC, Dijkman KP, Kooi EMW, Villamor E, Kroon AA, Visser R, Vijlbrief DC, de Tollenaer SM, Cools F, van Laere D, Johansson AB, Hocq C, Zecic A, Adang E, Donders R, de Vries W, van Heijst AFJ, de Boode WP. Early treatment versus expectative management of patent ductus arteriosus in preterm infants: a multicentre, randomised, non-inferiority trial in Europe (BeNeDuctus trial). BMC Pediatr 2018; 18:262. [PMID: 30077184 PMCID: PMC6090763 DOI: 10.1186/s12887-018-1215-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 07/09/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Much controversy exists about the optimal management of a patent ductus arteriosus (PDA) in preterm infants, especially in those born at a gestational age (GA) less than 28 weeks. No causal relationship has been proven between a (haemodynamically significant) PDA and neonatal complications related to pulmonary hyperperfusion and/or systemic hypoperfusion. Although studies show conflicting results, a common understanding is that medical or surgical treatment of a PDA does not seem to reduce the risk of major neonatal morbidities and mortality. As the PDA might have closed spontaneously, treated children are potentially exposed to iatrogenic adverse effects. A conservative approach is gaining interest worldwide, although convincing evidence to support its use is lacking. METHODS This multicentre, randomised, non-inferiority trial is conducted in neonatal intensive care units. The study population consists of preterm infants (GA < 28 weeks) with an echocardiographic-confirmed PDA with a transductal diameter > 1.5 mm. Early treatment (between 24 and 72 h postnatal age) with the cyclooxygenase inhibitor (COXi) ibuprofen (IBU) is compared with an expectative management (no intervention intended to close a PDA). The primary outcome is the composite of mortality, and/or necrotising enterocolitis (NEC) Bell stage ≥ IIa, and/or bronchopulmonary dysplasia (BPD) defined as the need for supplemental oxygen, all at a postmenstrual age (PMA) of 36 weeks. Secondary outcome parameters are short term sequelae of cardiovascular failure, comorbidity and adverse events assessed during hospitalization and long-term neurodevelopmental outcome assessed at a corrected age of 2 years. Consequences regarding health economics are evaluated by cost effectiveness analysis and budget impact analysis. DISCUSSION As a conservative approach is gaining interest, we investigate whether in preterm infants, born at a GA less than 28 weeks, with a PDA an expectative management is non-inferior to early treatment with IBU regarding to the composite outcome of mortality and/or NEC and/or BPD at a PMA of 36 weeks. TRIAL REGISTRATION This trial is registered with the Dutch Trial Register NTR5479 (registered on 19 October 2015), the registry sponsored by the United States National Library of Medicine Clinicaltrials.gov NCT02884219 (registered May 2016) and the European Clinical Trials Database EudraCT 2017-001376-28 .
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MESH Headings
- Humans
- Infant, Newborn
- Cost-Benefit Analysis
- Cyclooxygenase Inhibitors/therapeutic use
- Ductus Arteriosus, Patent/complications
- Ductus Arteriosus, Patent/drug therapy
- Ductus Arteriosus, Patent/mortality
- Ductus Arteriosus, Patent/surgery
- Enterocolitis, Necrotizing/etiology
- Ibuprofen/therapeutic use
- Infant, Extremely Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/mortality
- Ligation
- Research Design
- Time-to-Treatment
- Watchful Waiting/economics
- Multicenter Studies as Topic
- Equivalence Trials as Topic
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Affiliation(s)
- Tim Hundscheid
- Department of Paediatrics, Division of Neonatology, Radboud university medical centre Nijmegen, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Internal postal code 804, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Wes Onland
- Department of Neonatology, Academic Medical Centre Amsterdam, Emma Children’s hospital, Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, The Netherlands
| | - Bart van Overmeire
- Department of Paediatrics, Division of Neonatology, Cliniques Universitaires de Bruxelles, Erasme Hospital, Route de Lennik 808, 1070 Brussels, Belgium
| | - Peter Dijk
- Department of Paediatrics, Division of Neonatology, University Medical Centre Groningen, Beatrix Children’s Hospital, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Anton H. L. C. van Kaam
- Department of Paediatrics, Division of Neonatology, VU University Medical Centre Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Koen P. Dijkman
- Department of Neonatology, Maxima Medical Centre Veldhoven, de Run 4600, Postbus 7777, 5500 MB Veldhoven, The Netherlands
| | - Elisabeth M. W. Kooi
- Department of Paediatrics, Division of Neonatology, University Medical Centre Groningen, Beatrix Children’s Hospital, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Eduardo Villamor
- Department of Paediatrics, Division of Neonatology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - André A. Kroon
- Department of Paediatrics, Division of Neonatology, Erasmus Medical Centre Rotterdam, Sophia Children’s Hospital, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Remco Visser
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, Willem Alexander Children’s Hospital, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Daniel C. Vijlbrief
- Department of Paediatrics, Division of Neonatology, University Medical Centre Utrecht, Utrecht University, Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Susanne M. de Tollenaer
- Department of Paediatrics, Division of Neonatology, Isala Women’s and Children’s Hospital Zwolle, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Filip Cools
- Department of Neonatology, UZ Brussel – Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - David van Laere
- Department of Paediatrics, Division of Neonatology, Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Anne-Britt Johansson
- Department of Paediatrics, Division of Neonatology, Hôpital Universitaire des Enfants Reine Fabiola, Bruxelles, Jean Joseph Crocqlaan 15, 1020 Brussels, Belgium
| | - Catheline Hocq
- Department of Paediatrics, Division of Neonatology, Cliniques Universitaires St Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Alexandra Zecic
- Department of Paediatrics, Division of Neonatology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Eddy Adang
- Department of Health Evidence, Radboud university medical centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Rogier Donders
- Department of Health Evidence, Radboud university medical centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Willem de Vries
- Department of Paediatrics, Division of Neonatology, University Medical Centre Utrecht, Utrecht University, Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Arno F. J. van Heijst
- Department of Paediatrics, Division of Neonatology, Radboud university medical centre Nijmegen, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Internal postal code 804, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Willem P. de Boode
- Department of Paediatrics, Division of Neonatology, Radboud university medical centre Nijmegen, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Internal postal code 804, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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Abstract
Preterm infants are at increased risk for patent ductus arteriosus (PDA). Prolonged exposure to PDA may be deleterious and has been associated with neonatal morbidity and mortality. Although the molecular mechanisms underlying regulation of postnatal ductus arteriosus closure are not fully understood, clinical experience and research trials have informed recent changes in PDA management strategies and refocused treatment strategies on smaller subsets of infants who require intervention. This review examines current diagnostic and management approaches to PDA in preterm neonates.
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Affiliation(s)
- Maria Gillam-Krakauer
- Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
| | - Jeff Reese
- Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
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Cuzzolin L, Bardanzellu F, Fanos V. The dark side of ibuprofen in the treatment of patent ductus arteriosus: could paracetamol be the solution? Expert Opin Drug Metab Toxicol 2018; 14:855-868. [PMID: 29938546 DOI: 10.1080/17425255.2018.1492550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Patent ductus arteriosus (PDA) persistence is associated, in prematures, to several complications. The optimal PDA management is still under debate, especially regarding the best therapeutic approach and the time to treat. The available drugs are not exempt from contraindications and side effects; ibuprofen itself, although representing the first-choice therapy, can show nephrotoxicity and other complications. Paracetamol seems a valid alternative to classic nonsteroidal anti-inflammatory Drugs, with a lower toxicity. Areas covered: Through an analysis of the published literature on ibuprofen and paracetamol effects in preterm neonates, this review compares the available treatments for PDA, analyzing the mechanisms underlining ibuprofen-associated nephrotoxicity and the eventual paracetamol-induced hepatic damage, also providing an update of what has been yet demonstrated and a clear description of the still open issues. Expert Opinion: Paracetamol is an acceptable alternative in case of contraindication to ibuprofen; its toxicity, in this setting, is very low. Lower doses may be effective, with even fewer risks. In the future, paracetamol could represent an efficacious first-line therapy, although its safety, optimal dosage, and global impact have to be fully clarified through long-term trials, also in the perspective of an individualized and person-based therapy taking into account the extraordinary individual variability.
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Affiliation(s)
- Laura Cuzzolin
- a Department of Diagnostics & Public Health-Section of Pharmacology , University of Verona , Verona , Italy
| | - Flamina Bardanzellu
- b Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section , AOU and University of Cagliari , Cagliari , Italy
| | - Vassilios Fanos
- b Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section , AOU and University of Cagliari , Cagliari , Italy
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El-Farrash RA, El Shimy MS, El-Sakka AS, Ahmed MG, Abdel-Moez DG. Efficacy and safety of oral paracetamol versus oral ibuprofen for closure of patent ductus arteriosus in preterm infants: a randomized controlled trial. J Matern Fetal Neonatal Med 2018; 32:3647-3654. [PMID: 29695206 DOI: 10.1080/14767058.2018.1470235] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Objective: The objective of this study is to evaluate the efficacy and safety of oral paracetamol versus oral ibuprofen in the treatment of hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants. Study design: An interventional randomized case-control study, registered in ClinicalTrials.gov (NCT03265782), was conducted on 60 preterm infants with gestational age ≤34 weeks, postnatal age of 2-7 d and color Doppler echocardiographic evidence of hsPDA. Neonates were randomly assigned to two groups: 30 received oral ibuprofen and 30 received oral paracetamol. With failure of ductal closure, a second course of ibuprofen or paracetamol was given. The included newborns were subjected to detailed history, clinical examination, laboratory investigations that included complete blood count, renal, and liver function tests and echocardiographic evaluation. Results: Oral paracetamol was as effective as ibuprofen for the closure of patent ductus arteriosus (PDA) with one course of treatment (p > .05). Moreover, oral paracetamol was superior to ibuprofen among neonates who needed second course of treatment with significant decrease in end diastolic flow velocity in the left pulmonary artery (0.35 ± 0.09 versus 0.19 ± 0.06, p = .014), right ventricular systolic pressure (40.50 ± 12.91 versus 20.50 ± 0.58, p = .016) and left atrium to aortic root ratio (1.23 ± 0.14 versus 1.07 ± 0.04, p = .046) when compared to ibuprofen group. Furthermore, the mean difference between pre- and post-treatment PDA size was significantly higher in the paracetamol group compared with ibuprofen group after the second course of treatment (1.07 ± 0.32 versus 0.73 ± 0.38, p = .024). Oral paracetamol was comparable with ibuprofen in terms of the rate of non-surgical ductal closure [28 (93.3%) versus 24 (80%), p = .591]. In addition, oral paracetamol was as safe as oral ibuprofen in terms of gastrointestinal perforation or bleeding, necrotizing enterocolitis, bronchopulmonary dysplasia, intraventricular hemorrhage, thrombocytopenia, hepatic or renal dysfunction. Conclusions: Oral paracetamol is an effective and well-tolerated first-line drug treatment for PDA in premature infants.
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Affiliation(s)
- Rania A El-Farrash
- a Department of Pediatrics, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Mohammed S El Shimy
- a Department of Pediatrics, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Abeer S El-Sakka
- a Department of Pediatrics, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Manal G Ahmed
- b Neonatal Intensive Care Unit at the Maternity Hospital , Ain Shams University , Cairo , Egypt
| | - Dina G Abdel-Moez
- b Neonatal Intensive Care Unit at the Maternity Hospital , Ain Shams University , Cairo , Egypt
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Ohlsson A, Shah PS. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants. Cochrane Database Syst Rev 2018; 4:CD010061. [PMID: 29624206 PMCID: PMC6494526 DOI: 10.1002/14651858.cd010061.pub3] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND In preterm newborns, the ductus arteriosus frequently fails to close and the infants require medical or surgical closure of the patent ductus arteriosus (PDA). A PDA can be treated surgically; or medically with one of two prostaglandin inhibitors, indomethacin or ibuprofen. Case reports suggest that paracetamol may be an alternative for the closure of a PDA. An association between prenatal or postnatal exposure to paracetamol and later development of autism or autism spectrum disorder has been reported. OBJECTIVES To determine the effectiveness and safety of intravenous or oral paracetamol compared with placebo or no intervention, intravenous indomethacin, intravenous or oral ibuprofen, or with other cyclo-oxygenase inhibitors for treatment of an echocardiographically diagnosed PDA in preterm or low birth weight infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 10), MEDLINE via PubMed (1966 to 6 November 2017), Embase (1980 to 6 November 2017), and CINAHL (1982 to 6 November 2017). We searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCT) and quasi-randomised trials. SELECTION CRITERIA We included RCTs in which paracetamol was compared to no intervention, placebo or other agents used for closure of PDA irrespective of dose, duration and mode of administration in preterm (≤ 34 weeks' postmenstrual age) infants. We both reviewed the search results and made a final selection of potentially eligible articles by discussion. We included studies of both prophylactic and therapeutic use of paracetamol. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of evidence for the following outcomes when data were available: failure of ductal closure after the first course of treatment; neurodevelopmental impairment; all-cause mortality during initial hospital stay (death); gastrointestinal bleed or stools positive for occult blood; and serum levels of creatinine after treatment (µmol/L). MAIN RESULTS We included eight studies that reported on 916 infants. One of these studies compared paracetamol to both ibuprofen and indomethacin. Five studies compared treatment of PDA with paracetamol versus ibuprofen and enrolled 559 infants. There was no significant difference between paracetamol and ibuprofen for failure of ductal closure after the first course of drug administration (typical risk ratio (RR) 0.95, 95% confidence interval (CI) 0.75 to 1.21; typical risk difference (RD) -0.02, 95% CI -0.09 to 0.09); I² = 0% for RR and RD; moderate quality of evidence. Four studies (n = 537) reported on gastrointestinal bleed which was lower in the paracetamol group versus the ibuprofen group (typical RR 0.28, 95% CI 0.12 to 0.69; typical RD -0.06, 95% CI -0.09 to -0.02); I² = 0% for RR and RD; number needed to treat for an additional beneficial outcome (NNTB) 17 (95% CI 11 to 50); moderate quality of evidence. The serum levels of creatinine were lower in the paracetamol group compared with the ibuprofen group in four studies (moderate quality of evidence), as were serum bilirubin levels following treatment in two studies (n = 290). Platelet counts and daily urine output were higher in the paracetamol group compared with the ibuprofen group. One study reported on long-term follow-up to 18 to 24 months of age following treatment with paracetamol versus ibuprofen. There were no significant differences in the neurological outcomes at 18 to 24 months (n = 61); (low quality of evidence).Two studies compared prophylactic administration of paracetamol for a PDA with placebo or no intervention in 80 infants. Paracetamol resulted in a lower rate of failure of ductal closure after 4 to 5 days of treatment compared to placebo or no intervention which was of borderline significance for typical RR 0.49 (95% CI 0.24 to 1.00; P = 0.05); but significant for typical RD -0.21 (95% CI -0.41 to -0.02); I² = 0 % for RR and RD; NNTB 5 (95% CI 2 to 50); (low quality of evidence).Two studies (n = 277) compared paracetamol with indomethacin. There was no significant difference in the failure to close a PDA (typical RR 0.96, 95% CI 0.55 to 1.65; I² = 11%; typical RD -0.01, 95% CI -0.09 to 0.08; I² = 17%) (low quality of evidence). Serum creatinine levels were significantly lower in the paracetamol group compared with the indomethacin group and platelet counts and daily urine output were significantly higher in the paracetamol group. AUTHORS' CONCLUSIONS Moderate-quality evidence according to GRADE suggests that paracetamol is as effective as ibuprofen; low-quality evidence suggests paracetamol to be more effective than placebo or no intervention; and low-quality evidence suggests paracetamol as effective as indomethacin in closing a PDA. There was no difference in neurodevelopmental outcome in children exposed to paracetamol compared to ibuprofen; however the quality of evidence is low and comes from only one study. In view of concerns raised regarding neurodevelopmental outcomes following prenatal and postnatal exposure to paracetamol, long-term follow-up to at least 18 to 24 months' postnatal age must be incorporated in any studies of paracetamol in the newborn population. At least 19 ongoing trials have been registered. Such trials are required before any recommendations for the possible routine use of paracetamol in the newborn population can be made.
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Affiliation(s)
- Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoCanadaM5G 1X5
| | - Prakeshkumar S Shah
- University of Toronto Mount Sinai HospitalDepartment of Paediatrics and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoCanadaM5G 1XB
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Dowd LA, Wheeler BJ, Al-Sallami HS, Broadbent RS, Edmonds LK, Medlicott NJ. Paracetamol treatment for patent ductus arteriosus: practice and attitudes in Australia and New Zealand. J Matern Fetal Neonatal Med 2018; 32:3039-3044. [DOI: 10.1080/14767058.2018.1456520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- L. A. Dowd
- Otago School of Pharmacy, Otago, New Zealand
| | - B. J. Wheeler
- Department of Women’s and Children’s Health, Dunedin School of Medicine, University of Otago, Otago, New Zealand
| | | | - R. S. Broadbent
- Department of Women’s and Children’s Health, Dunedin School of Medicine, University of Otago, Otago, New Zealand
| | - L. K. Edmonds
- Department of Women’s and Children’s Health, Dunedin School of Medicine, University of Otago, Otago, New Zealand
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Dani C, Poggi C, Cianchi I, Corsini I, Vangi V, Pratesi S. Effect on cerebral oxygenation of paracetamol for patent ductus arteriosus in preterm infants. Eur J Pediatr 2018; 177:533-539. [PMID: 29372379 DOI: 10.1007/s00431-018-3086-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 01/06/2018] [Accepted: 01/09/2018] [Indexed: 01/24/2023]
Abstract
UNLABELLED Paracetamol seems to have similar success rates compared with indomethacin and ibuprofen in closing patent ductus arteriosus (PDA) in preterm infants, but with a better safety profile. The aim of our study was to evaluate the possible effects of paracetamol on cerebral oxygenation and cerebral blood flow velocity (CBFV). Infants with gestational age < 32 weeks with hemodynamically significant PDA (hsPDA) were prospectively studied by near infrared spectroscopy (NIRS) after the first dose of paracetamol (15 mg/kg) or ibuprofen (10 mg/kg). Cerebral regional oxygenation (rSO2C) and fractional oxygen extraction ratio (FOEC) were recorded 30 min before (T0) and 60 ± 20 min (T1), 180 ± 30 min (T2), and 360 ± 30 min (T3) after the beginning of drug infusion. Moreover, mean flow velocity (Vmean) and resistance index (RI = PSV-DV/PSV) measured with Doppler ultrasound in pericallosal artery were recorded at the same times. Significant changes in rSO2C and FOEC were not found during the study period within and between the groups. Similarly, Vmean did not vary in infants treated with paracetamol or ibuprofen, while RI decreased in the ibuprofen group. CONCLUSION The treatment of hsPDA with paracetamol does not affect cerebral oxygenation in very preterm infants; there were no differences in cerebral oxygenation in infants treated with paracetamol or ibuprofen, although in the ibuprofen group, the possible closure progression of PDA was associated to changes of RI. What is Known: • Paracetamol has similar success rates to indomethacin and ibuprofen in closing PDA with a better safety profile since previous studies did not report adverse effects. What is New: • Paracetamol does not affect cerebral oxygenation and perfusion in very preterm infants with PDA and this confirms its good safety profile.
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Affiliation(s)
- Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Viale Morgagni, 85, Florence, Firenze, Italy. .,Department of Neurosciences, Psychology, Drug Research, and Child Health, University of Florence, Florence, Italy.
| | - Chiara Poggi
- Division of Neonatology, Careggi University Hospital of Florence, Viale Morgagni, 85, Florence, Firenze, Italy
| | - Ilaria Cianchi
- Division of Neonatology, Careggi University Hospital of Florence, Viale Morgagni, 85, Florence, Firenze, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Viale Morgagni, 85, Florence, Firenze, Italy
| | - Venturella Vangi
- Division of Neonatology, Careggi University Hospital of Florence, Viale Morgagni, 85, Florence, Firenze, Italy
| | - Simone Pratesi
- Division of Neonatology, Careggi University Hospital of Florence, Viale Morgagni, 85, Florence, Firenze, Italy
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de Albuquerque Botura C, da Rocha BA, Balensiefer T, Ames FQ, Bersani-Amado CA, Nakamura Cuman RK. Oral pharmacological treatment for patent ductus arteriosus in premature neonates with hemodynamic repercussions. ASIAN PAC J TROP MED 2017; 10:1080-1083. [PMID: 29203106 DOI: 10.1016/j.apjtm.2017.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 08/29/2017] [Accepted: 09/16/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of oral indomethacin, ibuprofen, and paracetamol in oral dosage form on patent ductus arteriosus (PDA) in premature neonates with significant clinical and hemodynamic repercussions (CHRs) and to determine the effect of these respective treatments on renal function. METHODS A retrospective study of cases of PDA in premature neonates in the Neonatal Intensive Care Unit was conducted. The treatments consisted of indomethacin [0.2 mg/(kg·d), 3-day cycle], ibuprofen [10 mg/(kg·d) followed by 5 mg/(kg·d), 3-day cycle], and paracetamol (15 mg/kg every 6 h, 5-day cycle). The drugs were administered as an oral solution. The following variables were considered: gestational age, newborn weight at birth, Apgar score, diuresis, serum creatinine and urea levels, and serum electrolyte levels (sodium and potassium). RESULTS Treatment with indomethacin presented efficacy of 87.5% in closure of the ductus with a mean outcome period of 3.5 d. In premature neonates with CHRs and contraindications for indomethacin, the initial treatment with either ibuprofen or paracetamol failed to close the ductus. However, when this treatment was followed by indomethacin, closure occurred in 66.7% of the neonates, with an outcome period of 9.66 d. The initial treatment with one cycle of ibuprofen followed by one or two cycles of paracetamol failed to close the ductus. CONCLUSIONS Oral indomethacin was effective for closure of the PDA in premature neonates with severe CHRs. Oral paracetamol or ibuprofen for PDA closure in premature neonates with severe CHRs and contraindications for indomethacin was ineffective. However, results in clinical improvements of neonates allowed the subsequent use of indomethacin and successful closure of the ductus. A significant reduction of diuresis occurred in neonates who were treated with indomethacin, either as a first-line treatment or after the failure of ibuprofen or paracetamol.
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Affiliation(s)
| | - Bruno Ambrósio da Rocha
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Franciele Queiroz Ames
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Paraná, Brazil
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Rodríguez-Balderrama I, Morales-Rodríguez I, Sánchez-Cortez R, Tijerina-Guajardo M. Hemodynamically unstable ductus arteriosus treated with paracetamol in a tertiary care hospital in the northeast of Mexico. MEDICINA UNIVERSITARIA 2017. [DOI: 10.1016/j.rmu.2017.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Kulkarni VV, Dutta S, Sundaram V, Saini SS. Preterm Thrombocytopenia and Delay of Ductus Arteriosus Closure. Pediatrics 2016; 138:peds.2016-1627. [PMID: 27681010 DOI: 10.1542/peds.2016-1627] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate whether preterm thrombocytopenia within 24 hours of birth is associated with delayed closure of patent ductus arteriosus (PDA) and higher proportion of hemodynamically significant PDA (Hs-PDA). METHODS Neonates (gestation 260/7-336/7 weeks, age <24 hours) with known platelet count and PDA on echocardiogram were prospectively enrolled. Asphyxia, congenital infections, structural heart disease, major malformations and clinical sepsis were exclusions. Subjects were recruited in groups A (n = 35), B (n = 18), and C (n = 17) [platelet counts >150,000, 100,000-150,000 and <100,000 per μL respectively] and underwent daily echocardiography until first closure of PDA, death, or day 10. RESULTS The primary outcome was time to first closure of PDA. Secondary outcomes included proportion with PDA at 72 hours and 7 days, Hs-PDA, and PDA needing treatment. In groups A, B, and C, median (first-third quartile) platelet counts (×100000/μL) were 2.28 (1.94-3.19), 1.25 (1.14-1.37), and 0.68 (0.54-0.83) and time to PDA closure was 2 (2-2), 2 (2-3), and 10 (6-10) days, respectively (log-rank test, P < .001). On Cox proportional hazard regression, platelet count (in multiples of 10 000 /μL) independently predicted time to PDA closure (adjusted hazard ratio: 1.045; 95% confidence interval: 1.019-1.07). On day 7, 47.1% neonates in group C had PDA and none in groups A and B (P < .001). CONCLUSIONS Thrombocytopenia within 24 hours of birth independently predicts delayed PDA closure and PDA on day 7 in preterm neonates.
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Affiliation(s)
- Vinay Vamadev Kulkarni
- Newborn Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sourabh Dutta
- Newborn Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Venkataseshan Sundaram
- Newborn Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shiv Sajan Saini
- Newborn Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Yang B, Gao X, Ren Y, Wang Y, Zhang Q. Oral paracetamol vs. oral ibuprofen in the treatment of symptomatic patent ductus arteriosus in premature infants: A randomized controlled trial. Exp Ther Med 2016; 12:2531-2536. [PMID: 27698754 PMCID: PMC5038853 DOI: 10.3892/etm.2016.3676] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 08/23/2016] [Indexed: 01/12/2023] Open
Abstract
The aim of the present study was to analyze the changes of plasma and urinary prostaglandin E2 (PGE2) levels in preterm infants with symptomatic patent ductus arteriosus (sPDA) treated with oral ibuprofen and acetaminophen. A total of 87 preterm infants with sPDA admitted to the Neonatal Ward of the Affiliated Xuzhou Hospital of Medical College of Southeast University from October, 2012 to June, 2015 were selected and randomly divided into the ibuprofen group (n=43, 10 mg/kg ibuprofen administered orally as initial dose, followed by 5 mg/kg during the first 24 and 48 h later) and acetaminophen group (n=44, 15 mg/kg acetaminophen administered orally once every 6 h for three days). The levels of plasma and urinary PGE2 in the two groups were estimated before and after treatment. The treatment of sPDA infants with ibuprofen (ibuprofen group) or acetaminophen (acetaminophen group) caused a significant decrease in the plasma and urinary PGE2 levels in comparison with plasma and urinary PGE2 levels before treatment (P<0.05). Furthermore, plasma and urinary PGE2 levels in the acetaminophen group (45.0±36.9 ng/l) were significantly lower than those in the ibuprofen group (73.5±44.8 ng/l, P=0.002). The arterial duct closure rate was similar between the acetaminophen [31 (70.5%)] and ibuprofen groups [33 (76.7%), P=0.506]. The incidence of oliguria was less among sPDA infants of the acetaminophen group [1 (2.3%)] than observed among the sPDA infants of the ibuprofen group [6 (14.0%)]; however, this difference was not statistically significant (P=0.108). Additionally, the incidences of fecal occult blood positive rate, intraventricular hemorrhage, neonatal necrotizing enterocolitis and bronchopulmonary dysplasia were distributed similarly in the ibuprofen and acetaminophen groups (P>0.05). The levels of platelet, serum creatinine and alanine transaminase showed no significant changes between the ibuprofen and acetaminophen groups (P>0.05). Following treatment with ibuprofen or acetaminophen, the extent of decrease of plasma and urinary PGE2 was significantly higher among sPDA infants with oliguria (135.0±38.0 ng/l) than that observed in sPDA infants without oliguria (52.5±37.0 ng/l) (P=0.01). The study also found a significant correlation between plasma and urinary PGE2 levels (r=0.648, P=0.01) and the coefficient of variation of urinary PGE2 (0.427) was less than that of plasma PGE2 (0.539). The clinical efficacy of oral ibuprofen and acetaminophen in the treatment of preterm infants with sPDA was similar with low adverse events, whereas acetaminophen-induced PGE2 levels were less than the levels observed in the ibuprofen-treated group. The incidence of oliguria was also lower in the acetaminophen group compared to the ibuprofen group. In addition, monitoring urinary PGE2 levels was more suitable because of its non-invasiveness in the clinical setting than monitoring of plasma PGE2 in preterm infants with sPDA.
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Affiliation(s)
- Bo Yang
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
| | - Xiangyu Gao
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
| | - Yi Ren
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
| | - Yun Wang
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
| | - Qinglin Zhang
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
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Valerio E, Valente MR, Salvadori S, Frigo AC, Baraldi E, Lago P. Intravenous paracetamol for PDA closure in the preterm: a single-center experience. Eur J Pediatr 2016; 175:953-66. [PMID: 27146832 DOI: 10.1007/s00431-016-2731-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 04/23/2016] [Accepted: 04/28/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED Increasing recent evidence favors paracetamol use for patent ductus arteriosus (PDA) closure in preterms. Our study aims were (1) to assess efficacy and safety of intravenous (i.v.) paracetamol for PDA closure in a 23-32-week preterm population, as "first-line" (when traditional ibuprofen treatment was contraindicated) or "rescue" treatment (after ibuprofen failed), and (2) to identify predictors of PDA closure. The cumulative efficacy of consecutive cycles of i.v. paracetamol on PDA closure was confirmed after both "first-line" and "rescue" treatment, the overall PDA closure rates being, respectively, 56.7 and 61.1 % (p = 0.7624) after two cycles and 63.3 and 77.8 % (p = 0.2959) after three cycles. No toxicity was apparent after either "first-line" or "rescue" i.v. paracetamol treatment. On multivariate analysis, gestational age (GA) emerged as an independent predictor of PDA closure in the "first-line" i.v. paracetamol treatment group, while clinical risk index for babies (CRIB) score (a patient risk index based on birth weight, GA at birth, sex, patient's temperature on admission, and maximum base excess in first 12 h of life) was an independent predictor of PDA closure failure in the "rescue" group. CONCLUSION I.V. paracetamol proved effective in our study population. Randomized control trials (RCTs) are warranted to further investigate the efficacy and safety of i.v. paracetamol for PDA closure in preterms. WHAT IS KNOWN • Oral paracetamol has been judged as effective as oral ibuprofen for PDA closure in the preterm. • To date, only a handful of non-randomized studies exist to support the effectiveness of i.v. paracetamol in PDA closure. What is New: • Our observations confirm the clinical efficacy of i.v. paracetamol for PDA closure in a very low birth weight (VLBW)/extremely low birth weight (ELBW) preterm population. • Gestational age and CRIB score emerge as independent predictors of PDA closure.
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Affiliation(s)
- Enrico Valerio
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy.
| | - Marta Rossella Valente
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy
| | - Sabrina Salvadori
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy
| | - Anna Chiara Frigo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Medical School, Padova, Italy
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy
| | - Paola Lago
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy
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Bagheri MM, Niknafs P, Sabsevari F, Torabi MH, Bahman Bijari B, Noroozi E, Mossavi H. Comparison of Oral Acetaminophen Versus Ibuprofen in Premature Infants With Patent Ductus Arteriosus. IRANIAN JOURNAL OF PEDIATRICS 2016; 26:e3975. [PMID: 27713809 PMCID: PMC5045561 DOI: 10.5812/ijp.3975] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/28/2016] [Accepted: 02/05/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is a common cause of morbidity. The aim of this study was to compare the efficacy of oral Acetaminophen and oral Ibuprofen for the closure of patent ductus arteriosus (PDA) in preterm infants. OBJECTIVES This study demonstrated that, there was no significant difference between treatment of PDA with either oral Acetaminophen or oral Ibuprofen in preterm neonates. PATIENTS AND METHODS This clinical trial, randomized study, enrolled 120 infants, with a gestational age of < 37 weeks, who were admitted in neonatal intensive care unit of Afzalipour hospital, Kerman, Iran, in 2014. PDA was confirmed echocardiographically. The trial was registered in Iranian registry of clinical trials (Reg. No. 25542). Sixty-seven infants received oral Acetaminophen (15mg/kg every six hours for three days) and 62 infants received Ibuprofen (an initial dose of 20 mg/kg, followed by 10 mg/kg at 24 and 48 hours). To evaluate the efficacy of the treatment, a second echocardiography was done after completing the treatment. RESULTS After the first course of the treatment, PDA closed in 55 (82.1 %) patients who received oral Acetaminophen vs. 47 (75.8 %) of those given oral Ibuprofen (P = 0.38). After the second course of treatment, PDA closed in 50 % of oral Acetaminophen group and 73.3% of oral Ibuprofen group (P = 0.21). CONCLUSIONS This study demonstrated that, there was no significant difference between treatment of PDA with either oral Acetaminophen or oral Ibuprofen in preterm neonates. Oral Ibuprofen can effectively close PDA but is unfortunately associated with some adverse effects limiting its utility thus we studied an alternative drug with similar efficacy and less adverse effects. This study has recommends Acetaminophen with minimal complications for the treatment of PDA in preterm neonates instead of Ibuprofen.
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Affiliation(s)
| | - Pedram Niknafs
- Afzalipour Medical Center, Kerman University of Medical Sciences, Kerman, IR Iran
| | - Fatemeh Sabsevari
- Afzalipour Medical Center, Kerman University of Medical Sciences, Kerman, IR Iran
- Corresponding author: Fatemeh Sabsevari, Afzalipour Medical Center, Kerman University of Medical Sciences, Kerman, IR Iran. Tel: +98-9131951947, E-mail:
| | | | | | - Elahe Noroozi
- Afzalipour Medical Center, Kerman University of Medical Sciences, Kerman, IR Iran
| | - Hamid Mossavi
- Afzalipour Medical Center, Kerman University of Medical Sciences, Kerman, IR Iran
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Dani C, Poggi C, Mosca F, Schena F, Lista G, Ramenghi L, Romagnoli C, Salvatori E, Rosignoli MT, Lipone P, Comandini A. Efficacy and safety of intravenous paracetamol in comparison to ibuprofen for the treatment of patent ductus arteriosus in preterm infants: study protocol for a randomized control trial. Trials 2016; 17:182. [PMID: 27038924 PMCID: PMC4818852 DOI: 10.1186/s13063-016-1294-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 03/16/2016] [Indexed: 01/25/2023] Open
Abstract
Background Patent ductus arteriosus (PDA) is one of most common complications in preterm infants. Although ibuprofen represents the first choice for the closure of PDA, this treatment can cause severe gastrointestinal and adverse renal effects and worsen platelet function. The successful closure of the PDA with paracetamol has been recently reported in several preterm infants, and the safety of paracetamol for this use has been suggested by the available data. Methods/design We present the design of a randomized, multicenter, controlled study, whose aim is to assess the effectiveness and safety of intravenous paracetamol in comparison to intravenous ibuprofen for the treatment of PDA in preterm infants. A total of 110 infants born at 25+0 to 31+6 weeks of gestational age will be enrolled and randomized to receive paracetamol or ibuprofen (55 patients per group) starting at 24–72 h of life. The primary endpoint of the study is the comparison of the PDA closing rate observed after a 3-day course with paracetamol or ibuprofen. The secondary endpoints include the closure rate of PDA after the second course of treatment with ibuprofen, the re-opening rate of the PDA, the incidence of surgical ligation, and the occurrence of adverse effects. Discussion The results of this study will provide new information about the possible use of paracetamol in the treatment of PDA. Paracetamol could offer several important therapeutic advantages over current treatment options, and it could become the treatment of choice for the management of PDA, mainly due to its more favorable side effect profile. Trial registration Clinicaltrials.gov NCT02422966. Eudract no. 2013-003883-30. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1294-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carlo Dani
- Department of Neuroscience, Psychology, Drug Research and Child Health, Careggi University Hospital of Florence, Largo Brambilla 3, 50134, Firenze, Italy.
| | - Chiara Poggi
- Division of Neonatology, Careggi University Hospital of Florence, Largo Brambilla 3, 50134, Firenze, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Department of Mother and Infant Science, Fondazione IRCCS "Ca' Granda" Ospedale Maggiore Policlinico, University of Milan, Via Della Commenda 12, 20122, Milano, Italy
| | - Federico Schena
- Neonatal Intensive Care Unit, Department of Mother and Infant Science, Fondazione IRCCS "Ca' Granda" Ospedale Maggiore Policlinico, University of Milan, Via Della Commenda 12, 20122, Milano, Italy
| | - Gianluca Lista
- Division of Neonatology, "V. Buzzi" Children Hospital of Milan, Via Castelvetro 22, 20154, Milan, Italy
| | - Luca Ramenghi
- Department of Neonatology Obstetrics and Neuroscience, G. Gaslini Children's University Hospital of Genova, Via Gerolamo Gaslini 5, 16147, Genova, Italy
| | - Costantino Romagnoli
- Division of Neonatology, Catholic University of Rome, Largo Agostino Gemelli 8, 00168, Roma, Italy
| | - Enrica Salvatori
- Angelini S.p.A. - Piazzale della Stazione, 00071, S. Palomba -Pomezia, Roma, Italy
| | | | - Paola Lipone
- Angelini S.p.A. - Piazzale della Stazione, 00071, S. Palomba -Pomezia, Roma, Italy
| | - Alessandro Comandini
- Angelini S.p.A. - Piazzale della Stazione, 00071, S. Palomba -Pomezia, Roma, Italy
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Sivanandan S, Agarwal R. Pharmacological Closure of Patent Ductus Arteriosus: Selecting the Agent and Route of Administration. Paediatr Drugs 2016; 18:123-38. [PMID: 26951240 DOI: 10.1007/s40272-016-0165-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Opinions are divided regarding the management of a persistently patent ductus arteriosus (PDA). Some of the adverse effects associated with a large hemodynamically significant duct, including prolonged ventilation, pulmonary hemorrhage, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), and mortality, indicate that active management of infants with large ductal shunts may sometimes be necessary. Indomethacin and ibuprofen are the two US FDA-approved cyclooxygenase (COX) inhibitors used for the closure of a ductus in preterm babies. Both these drugs are effective in 70-80% of extremely low birthweight infants. Treatment with COX inhibitors may be associated with renal impairment, gastrointestinal hemorrhage, NEC, and spontaneous intestinal perforation when given concurrently with steroids, as well as changes in cerebrovascular auto-regulation. Ibuprofen appears to be a better choice for PDA closure, with a better side effect profile and efficacy that equals that of indomethacin. However, long-term outcome studies of ibuprofen are lacking, and prophylactic ibuprofen is ineffective in decreasing severe IVH. The choice of one drug over the other also depends on local availability of both drugs and the intravenous or enteral preparation. The oral preparation of ibuprofen appears as effective as the intravenous preparation. The use of paracetamol to close a hemodynamically significant PDA has increased in recent years. Paracetamol also decreases prostacyclin synthesis; however, unlike COX inhibitors, it does not have a peripheral vaso-constrictive effect and can be given to infants with contraindications to non-steroidal anti-inflammatory drugs. It appears to have similar efficacy based on limited data available from randomized trials. Until more data are available on efficacy, safety, and long-term outcomes, it cannot be recommended as the first choice.
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Affiliation(s)
- Sindhu Sivanandan
- Division of Neonatology, Department of Pediatrics (Newborn Health Knowledge Center (NHKC), ICMR Center for Advanced Research in Newborn Health and WHO Collaborating Centre for Newborn Training and Research, New Private Ward-1st Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ramesh Agarwal
- Division of Neonatology, Department of Pediatrics (Newborn Health Knowledge Center (NHKC), ICMR Center for Advanced Research in Newborn Health and WHO Collaborating Centre for Newborn Training and Research, New Private Ward-1st Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Terrin G, Conte F, Oncel MY, Scipione A, McNamara PJ, Simons S, Sinha R, Erdeve O, Tekgunduz KS, Dogan M, Kessel I, Hammerman C, Nadir E, Yurttutan S, Jasani B, Alan S, Manguso F, De Curtis M. Paracetamol for the treatment of patent ductus arteriosus in preterm neonates: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2016; 101:F127-36. [PMID: 26283668 DOI: 10.1136/archdischild-2014-307312] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 07/24/2015] [Indexed: 01/27/2023]
Abstract
OBJECTIVES We performed a systematic review and meta-analysis of all the available evidence to assess the efficacy and safety of paracetamol for the treatment of patent ductus arteriosus (PDA) in neonates, and to explore the effects of clinical variables on the risk of closure. DATA SOURCE MEDLINE, Scopus and ISI Web of Knowledge databases, using the following medical subject headings and terms: paracetamol, acetaminophen and patent ductus arteriosus. Electronic and manual screening of conference abstracts from international meetings of relevant organisations. Manual search of the reference lists of all eligible articles. STUDY SELECTION Studies comparing paracetamol versus ibuprofen, indomethacin, placebo or no intervention for the treatment of PDA. DATA EXTRACTION Data regarding efficacy and safety were collected and analysed. RESULTS Sixteen studies were included: 2 randomised controlled trials (RCTs) and 14 uncontrolled studies. Quality of selected studies is poor. A meta-analysis of RCTs does not demonstrate any difference in the risk of ductal closure (Mantel-Haenszel model, RR 1.07, 95% CI 0.87 to 1.33 and RR 1.03, 95% CI 0.92 to 1.16, after 3 and 6 days of treatment, respectively). Proportion meta-analysis of uncontrolled studies demonstrates a pooled ductal closure rate of 49% (95% CI 29% to 69%) and 76% (95% CI 61% to 88%) after 3 and 6 days of treatment with paracetamol, respectively. Safety profiles of paracetamol and ibuprofen are similar. CONCLUSIONS Efficacy and safety of paracetamol appear to be comparable with those of ibuprofen. These results should be interpreted with caution, taking into account the non-optimal quality of the studies analysed and the limited number of neonates treated with paracetamol so far.
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Affiliation(s)
- Gianluca Terrin
- Department of Gynecology-Obstetrics and Perinatal Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesca Conte
- Department of Pediatrics and Pediatric Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | - Mehmet Yekta Oncel
- Division of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Antonella Scipione
- Department of Pediatrics and Pediatric Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | - Patrick J McNamara
- Department of Neonatology, The Hospital for Sick Children, Toronto, Canada
| | - Sinno Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rahul Sinha
- Department of Pediatrics and Neonatology, 167 Military Hospital, Pathankot, Punjab, India
| | - Omer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University School of Medicine Children's Hospital, Ankara, Turkey
| | - Kadir S Tekgunduz
- Department of Neonatology, Ataturk University Medical Faculty, Erzurum, Turkey
| | - Mustafa Dogan
- Division of Cardiology, Department of Pediatrics, Pamukkale University, Denizli, Turkey
| | - Irena Kessel
- Department of Neonatology, Carmel Medical Center, Haifa, Israel
| | - Cathy Hammerman
- Department of Neonatology, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - E Nadir
- Department of Neonatology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Sadik Yurttutan
- Division of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Bonny Jasani
- Department of Neonatology, KEM Hospital, Mumbai, India
| | - Serdar Alan
- Division of Neonatology, Hitit University, Corum, Turkey
| | | | - Mario De Curtis
- Department of Pediatrics and Pediatric Neuropsychiatry, Sapienza University of Rome, Rome, Italy
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Sallmon H, Koehne P, Hansmann G. Recent Advances in the Treatment of Preterm Newborn Infants with Patent Ductus Arteriosus. Clin Perinatol 2016; 43:113-29. [PMID: 26876125 DOI: 10.1016/j.clp.2015.11.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A patent ductus arteriosus (PDA) is associated with several adverse clinical conditions. Several strategies for PDA treatment exist, although data regarding the benefits of PDA treatment on outcomes are sparse. Moreover, the optimal treatment strategy for preterm neonates with PDA remains subject to debate. It is still unknown whether and when PDA treatment should be initiated and which approach (conservative, pharmacologic, or surgical) is best for individual patients (tailored therapies). This article reviews the current strategies for PDA treatment with a special focus on recent developments such as oral ibuprofen, high-dose regimens, and the use of paracetamol (oral, intravenous).
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Affiliation(s)
- Hannes Sallmon
- Department of Neonatology, Charité University Medical Center, Augustenburger Platz 1, Berlin 13353, Germany
| | - Petra Koehne
- Department of Neonatology, Charité University Medical Center, Augustenburger Platz 1, Berlin 13353, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany.
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Langhendries JP, Allegaert K, Van Den Anker J, Veyckemans F, Smets F. Possible effects of repeated exposure to ibuprofen and acetaminophen on the intestinal immune response in young infants. Med Hypotheses 2016; 87:90-6. [DOI: 10.1016/j.mehy.2015.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 10/25/2015] [Accepted: 11/17/2015] [Indexed: 12/29/2022]
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Caffarelli C, Santamaria F, Cesari S, Sciorio E, Povesi-Dascola C, Bernasconi S. Advances in pediatrics in 2014: current practices and challenges in allergy, gastroenterology, infectious diseases, neonatology, nutrition, oncology and respiratory tract illnesses. Ital J Pediatr 2015; 41:84. [PMID: 26518317 PMCID: PMC4628263 DOI: 10.1186/s13052-015-0193-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/20/2015] [Indexed: 11/27/2022] Open
Abstract
Major advances in the conduct of pediatric practice have been reported in the Italian Journal of Pediatrics in 2014. This review highlights developments in allergy, gastroenterology, infectious diseases, neonatology, nutrition, oncology and respiratory tract illnesses. Investigations endorse a need to better educate guardians and improve nutritional management in food allergy. Management of hyperbilirubinemia in neonates and of bronchiolitis have been improved by position statements of scientific societies. Novel treatments for infant colic and inflammatory bowel diseases have emerged. Studies suggest the diagnostic utility of ultrasonography in diagnosing community-acquired pneumonia. Progress in infectious diseases should include the universal varicella vaccination of children. Recommendations on asphyxia and respiratory distress syndrome have been highlighted in neonatology. Studies have evidenced that malnutrition remains a common underestimated problem in developing countries, while exposure to cancer risk factors in children is not negligible in Western countries. Advances in our understanding of less common diseases such as cystic fibrosis, plastic bronchitis, idiopathic pulmonary hemosiderosis facilitate diagnosis and management. Researches have led to new therapeutic approaches in patent ductus arteriosus and pediatric malignancies.
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Affiliation(s)
- Carlo Caffarelli
- Clinica Pediatrica, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.
| | - Silvia Cesari
- Clinica Pediatrica, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.
| | - Elisa Sciorio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.
| | - Carlotta Povesi-Dascola
- Clinica Pediatrica, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.
| | - Sergio Bernasconi
- Pediatrics Honorary Member University Faculty, "G D' Annunzio" University of Chieti Pescara, Chieti, Italy.
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[Paracetamol (acetaminophen) use in neonatology: a (re)appreciation of an old drug]. Arch Pediatr 2015; 22:1064-71. [PMID: 26299912 DOI: 10.1016/j.arcped.2015.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/26/2015] [Accepted: 07/10/2015] [Indexed: 11/22/2022]
Abstract
In neonates, paracetamol is mainly used for its analgesic action. This drug is actually preferred by neonatologists because of its broad therapeutic index. Recently, it has been demonstrated that paracetamol is also an anti-cyclooxygenase (COX) medication through its inhibitory action on the peroxidase arm of central and peripheral COX (Boutaud et al., 2002; Toussaint et al., 2010; Graham et al., 2013; Hinz et al., 2008; Hinz and Brune, 2011). As such, this drug interferes with the synthesis of prostaglandins. This inhibition of peroxidase is, however, limited to a low concentration of arachidonic acid (AA) (around 2μM, in vitro) when the plasmatic concentration of paracetamol is experimentally 10μM, actually within the same range as compared to the therapeutic concentrations in vivo. This may partly explain its low anti-inflammatory effect as compared to ibuprofen and indomethacin, which exert their inhibition on COX whatever the AA concentrations are. This new well-demonstrated action of paracetamol on peripheral COX-2 of intact cells could explain recent observations making this drug a potential alternative in treating patent ductus arteriosus. However, the higher dosages that have been claimed by some authors in this indication still remain to be validated. This inhibition that paracetamol shows on the physiological synthesis of prostaglandins E2 (PGE2) could also explain some long-term immune deviations because the physiological concentration of PGE2 is a well-known actor in the genesis of immune homeostasis in the submucosal area. Indeed, recent epidemiology studies have pointed out immune deviations in children repeatedly exposed to paracetamol earlier in life. Consequently, this is actually the new discovery of an old drug. From these new data on paracetamol, a more focused pharmacovigilance on the long-term effects of paracetamol repeatedly given in the early stage should be urgently initiated.
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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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Memisoglu A, Alp Ünkar Z, Cetiner N, Akalın F, Ozdemir H, Bilgen HS, Ozek E. Ductal closure with intravenous paracetamol: a new approach to patent ductus arteriosus treatment. J Matern Fetal Neonatal Med 2015; 29:987-90. [PMID: 25781500 DOI: 10.3109/14767058.2015.1029912] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Indomethacin and ibuprofen are commonly used in the treatment of hemodynamically significant patent ductus arteriosus (hsPDA). These drugs are associated with serious adverse events, including gastrointestinal perforation, renal failure and bleeding. The role of paracetamol has been proposed for the treatment of PDA. METHODS We report a series of 11 neonates (birth weight: 415-1580 g; gestational age: 23-30.3 weeks) who were treated with paracetamol for a hsPDA. Neonates with hsPDA were treated with paracetamol in the presence of contraindications to ibuprofen or indomethacin. The condition of significant PDA was defined by the presence of at least one of the following criteria: internal ductal diameter # 1.4 mm/kg body weight, left atrium (LA)-to-aortic (Ao) root ratio > 1.4, unrestrictive pulsatile transductal flow, reverse or absent diastolic flow in the descending aorta along with clinical findings. Intravenous (IV) paracetamol was given at doses 15 mg/kg every 6 h for three days. RESULTS Successful ductal closure was achieved in 10 out of 11 babies (90.9%). No adverse or side effects were observed during the treatment. CONCLUSIONS On the basis of these results, paracetamol could be considered as a promising and safe therapy for the treatment of PDA in preterm infants.
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Affiliation(s)
| | | | - Nilufer Cetiner
- b Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine , Marmara University , Istanbul , Turkey
| | - Figen Akalın
- b Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine , Marmara University , Istanbul , Turkey
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Ohlsson A, Shah PS. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low-birth-weight infants. Cochrane Database Syst Rev 2015:CD010061. [PMID: 25758061 DOI: 10.1002/14651858.cd010061.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In preterm newborns, the ductus arteriosus frequently fails to close and the infants require medical or surgical closure of the patent ductus arteriosus (PDA). A PDA can be treated surgically or medically with one of two prostaglandin inhibitors, indomethacin or ibuprofen. Case reports suggest that paracetamol may be an alternative for the closure of a PDA. Concerns have been raised that in neonatal mice paracetamol may cause adverse effects on the developing brain, and an association between prenatal exposure to paracetamol and later development of autism or autism spectrum disorder has been reported. OBJECTIVES To determine the efficacy and safety of intravenous or oral paracetamol compared with placebo or no intervention, intravenous indomethacin, intravenous or oral ibuprofen, or with other cyclo-oxygenase inhibitors for closure of a PDA in preterm or low-birth-weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, EMBASE and CINAHL. We searched abstracts from the meetings of the Pediatric Academic Societies and the Perinatal Society of Australia and New Zealand. We searched clinicaltrials.gov; controlled-trials.com; anzctr.org.au; World Health Organization International Clinical Trials Registry Platform at who.int/ictrp for ongoing trials and the Web of Science for articles quoting identified randomised controlled trials. We searched the first 200 hits on Google Scholar(TM) to identify grey literature. All searches were conducted in December 2013. A repeat search of MEDLINE in August 2014 did not identify any new trials. SELECTION CRITERIA We identified two randomised controlled trials (RCTs) that compared oral paracetamol to oral ibuprofen for the treatment of an echocardiographically diagnosed PDA in infants born preterm (≤ 34 weeks postmenstrual age (PMA)). DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. MAIN RESULTS Two unmasked studies of treatment of PDA that enrolled 250 infants were included. The sequence of randomisation and the allocation to treatment groups were concealed in both studies. In one study the cardiologist assessing PDA closure was blinded to group allocation of the infant. In the other study it was not stated if that was the case or not. The quality of the trials, using GRADE, was low for the primary outcome of PDA closure and moderate for all other important outcomes. There was no significant difference between treatment with oral paracetamol versus oral ibuprofen for failure of ductal closure after the first course of drug administration (typical relative risk (RR) 0.90, 95% confidence interval (CI) 0.67 to 1.22; typical risk difference (RD) -0.04, 95% CI -0.16 to 0.08; I(2) = 0 % for RR and 23% for RD).There were no significant differences between the paracetamol and the ibuprofen groups in the secondary outcomes except for 'duration for need of supplemental oxygen' (mean difference -12 days, 95% CI -23 days to -2 days; 1 study, n = 90) and for hyperbilirubinaemia (RR 0.57, 95% CI 0.34 to 0.97; RD -0.15, 95% CI -0.29 to -0.01; number needed to treat to benefit (NNTB) 7, 95% CI 3 to 100 in favour of paracetamol; 1 study, n = 160). AUTHORS' CONCLUSIONS Although a limited number of infants with a PDA have been studied in randomised trials of low to moderate quality according to GRADE, oral paracetamol appears to be as effective in closing a PDA as oral ibuprofen. In view of a recent report in mice of adverse effects on the developing brain from paracetamol, and another report of an association between prenatal paracetamol and the development of autism or autism spectrum disorder in childhood, long-term follow-up to at least 18 to 24 months postnatal age must be incorporated in any studies of paracetamol in the newborn population. Such trials are required before any recommendations for the use of paracetamol in the newborn population can be made.
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Affiliation(s)
- Arne Ohlsson
- Departments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation, University of Toronto, 600 University Avenue, Toronto, ON, Canada, M5G 1X5
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Sancak S, Gokmen Yildirim T, Topcuoglu S, Yavuz T, Karatekin G, Ovali F. Oral versus intravenous paracetamol: which is better in closure of patent ductus arteriosus in very low birth weight infants? J Matern Fetal Neonatal Med 2014; 29:135-9. [PMID: 25471090 DOI: 10.3109/14767058.2014.989829] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To compare the efficacy of oral and intravenous paracetamol for closure of hemodynamically significant patent ductus arteriosus (HSPDA) in very low birth weight (VLBW) preterm infants. METHODS Eighteen VLBW infants with HSPDA treated with either intravenous (n = 10) or oral (n = 8) paracetamol at 60 mg/kg/d for three consecutive days were analysed retrospectively. Ductal closure rate and evaluation of liver function tests were the major outcomes. RESULTS After two courses of treatment, HSPDA closure rate was higher in oral paracetamol group than that in the intravenous paracetamol group (88% versus 70%), but it was not statistically significant (p = 0.588). Liver function tests were normal after the treatment. CONCLUSION Although it was not statistically significant, the cumulative closure rates were higher in oral paracetamol group than those in the intravenous group. Larger trials are needed to confirm these data.
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Affiliation(s)
| | | | | | - Taner Yavuz
- b Department of Pediatric Cardiology , Zeynep Kamil Maternity and Children's Training and Research Hospital , Istanbul , Turkey
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[Prostaglandins and the immune response at the intestinal submucosal level. A potential site for interference with the repeated use of paracetamol and ibuprofen at a young age?]. Arch Pediatr 2014; 22:311-9. [PMID: 25440768 DOI: 10.1016/j.arcped.2014.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 09/14/2014] [Accepted: 11/06/2014] [Indexed: 01/22/2023]
Abstract
Immune deviations have been shown to exponentially increase in young children. As a consequence, research investigating possible environmental reasons for this increase is considered a public health priority. An improved understanding of the immunity of the intestinal submucosal lamina propria has demonstrated the importance of prostaglandins (PGE2s) on its local development with general immune consequences further on. PGE2s appear at this intestinal submucosal level from the metabolism of arachidonic acid mediated by type-2 cyclooxygenases (COX2s) situated in the membranes of many immune cells. The potential risk of repeated inhibition of PGE2 synthesis at a young age has been demonstrated in experiments with animals systemically exposed to a non-steroidal anti-inflammatory drug (NSAID). The repeatedly exposed animal cannot develop tolerance to food antigens and exhibits autoimmune deviations. Acetaminophen (paracetamol) and ibuprofen are analgesic and antipyretic medications given to children either alone or in combination, most often without medical prescription. Recently, it has been demonstrated that paracetamol, like ibuprofen, also carries, besides its central action, a non-selective inhibitory action on peripheral COXs. However, this inhibitory action only relates to physiological concentrations of arachidonic acid and explains the difference in their respective anti-inflammatory effects. Since recently published data have repeatedly reported an increase of immune deviations associated with paracetamol exposure at a young age, it appears important to better understand the possible negative impact of excessive and repetitive inhibitions of the physiological synthesis of prostaglandins by COX2s in childhood during which all immune mechanisms are built up at the intestinal submucosal level. Therefore, a well-designed prospective strategy for pharmacovigilance of these COX inhibitors repeatedly given during childhood is urgently needed.
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Abstract
Objective: To evaluate the literature describing acetaminophen use in treatment of patent ductus arteriosus (PDA). Data Sources: Searches were conducted in MEDLINE with full text (EBSCOhost; 1946 to September 2014) using the search terms acetaminophen, paracetamol, and patent ductus arteriosus. The references of identified articles were reviewed to identify other relevant articles. Study Selection and Data Extraction: Human clinical trials and case reports limited to the English language were reviewed. In all, 12 case reports and 2 randomized, controlled clinical trials explored the use of acetaminophen in treating PDA. Data Synthesis: The case reports described the use of oral or intravenous acetaminophen in patients with contraindications to or who had previously failed nonsteroidal anti-inflammatory drug therapy for PDA. More than 76% of patients achieved successful PDA closure in reported cases. The clinical trials compared the efficacy of oral acetaminophen versus oral ibuprofen in preterm infants. Acetaminophen was noninferior to ibuprofen, with closure rates from 72.5% to 81.2%. The acetaminophen dose used in most case series and trials was 15 mg/kg dose every 6 hours for 3 days. Acetaminophen therapy was well tolerated, with only a few incidents of elevated liver enzymes being reported. Conclusion: Oral acetaminophen is an alternative to PDA therapy in preterm infants when indomethacin/ibuprofen is not effective or is contraindicated, and it may be considered before surgical ligation.
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Affiliation(s)
- Jennifer Le
- Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
| | - Mark A. Gales
- Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
- Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Barry J. Gales
- Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
- Integris Baptist Medical Center, Oklahoma City, OK, USA
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Kent AL, Koina ME, Gubhaju L, Cullen-McEwen LA, Bertram JF, Lynnhtun J, Shadbolt B, Falk MC, Dahlstrom JE. Indomethacin administered early in the postnatal period results in reduced glomerular number in the adult rat. Am J Physiol Renal Physiol 2014; 307:F1105-10. [PMID: 25186294 DOI: 10.1152/ajprenal.00328.2014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Indomethacin and ibuprofen are administered to close a patent ductus arteriosus (PDA) during active glomerulogenesis. Light and electron microscopic glomerular changes with no change in glomerular number were seen following indomethacin and ibuprofen treatment during glomerulogenesis at 14 days after birth in a neonatal rat model. This present study aimed to determine whether longstanding renal structural changes are present at 30 days and 6 mo (equivalent to human adulthood). Rat pups were administered indomethacin or ibuprofen antenatally on days 18-20 (0.5 mg·kg(-1)·dose(-1) indomethacin; 10 mg·kg(-1)·dose(-1) ibuprofen) or postnatally intraperitoneally from day 1 to 3 or day 1 to 5 (0.2 mg·kg(-1)·dose(-1) indomethacin; 10 mg·kg(-1)·dose(-1) ibuprofen). Control groups received no treatment or normal saline intraperitoneally. Pups were killed at 30 days of age and 6 mo of age. Tissue blocks from right kidneys were prepared for light and electron microscopic examination, while total glomerular number was determined in left kidneys using unbiased stereology. Eight pups were included in each group from 14 maternal rats. At 30 days and 6 mo, there were persistent electron microscopy abnormalities of the glomerular basement membrane in those receiving postnatal indomethacin and ibuprofen. There were no significant light microscopy findings at 30 days or 6 mo. At 6 mo, there were significantly fewer glomeruli in those receiving postnatal indomethacin but not ibuprofen (P = 0.003). In conclusion, indomethacin administered during glomerulogenesis appears to reduce the number of glomeruli in adulthood. Alternative options for closing a PDA should be considered including ibuprofen as well as emerging therapies such as paracetamol.
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Affiliation(s)
- A L Kent
- Department of Neonatology, Canberra Hospital, Woden, ACT, Australia; Australian National University Medical School, Canberra, ACT, Australia
| | - M E Koina
- Department of Anatomical Pathology, Canberra Hospital, Woden, ACT, Australia
| | - L Gubhaju
- Department of Anatomy and Developmental Biology, Monash University, Melbourne, Victoria, Australia; and
| | - L A Cullen-McEwen
- Department of Anatomy and Developmental Biology, Monash University, Melbourne, Victoria, Australia; and
| | - J F Bertram
- Department of Anatomy and Developmental Biology, Monash University, Melbourne, Victoria, Australia; and
| | - J Lynnhtun
- Department of Anatomical Pathology, Canberra Hospital, Woden, ACT, Australia
| | - B Shadbolt
- Clinical Epidemiology Unit, Canberra Hospital, Woden, ACT, Australia; Australian National University Medical School, Canberra, ACT, Australia
| | - M C Falk
- Department of Renal Medicine, Canberra Hospital, Woden, ACT, Australia; Australian National University Medical School, Canberra, ACT, Australia
| | - J E Dahlstrom
- Department of Anatomical Pathology, Canberra Hospital, Woden, ACT, Australia; Australian National University Medical School, Canberra, ACT, Australia
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