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Alghamdi FA, Bin Mahfooz MA, Almutairi HF, Alshaiban NS, Alotibi KE, Kabbani OM, Kabbani MS. Incidence, Risk Factors and Outcomes of Acute Kidney Injury in Neonates Undergoing Open-heart Surgeries: Single Center Experience. J Saudi Heart Assoc 2024; 36:70-78. [PMID: 38919507 PMCID: PMC11195661 DOI: 10.37616/2212-5043.1374] [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: 03/25/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 06/27/2024] Open
Abstract
Background Incidence and outcomes of acute kidney injury (AKI) among neonates who underwent open-heart surgery are not well highlighted in the literature. We aim to assess the incidence, risk factors, and outcome of AKI among neonates undergoing open-heart surgery. Methods This is a retrospective cohort study between 2016 and 2021 for all neonates requiring open heart surgery. The cases were divided into 2 groups: the AKI (index) group and the non-AKI (control) group. The two groups were statistically compared for risk factors, needs for dialysis, and outcomes. Results 100 patients fulfilled the inclusion criteria. Among them, 74 (74%) developed AKI, including 41 (55%), 15 (21%), and 18 (24%) patients in KDIGO stages 1, 2, and 3, respectively. Multivariate analysis comparing both groups demonstrated that low pre-operative creatinine (p = 0.01), prolonged bypass time (p = 0.0004) and high vasoactive inotropic score (VIS), (p = 0.0008) were risk factors for developing AKI post-operatively. Furthermore, in the AKI group, 17 (23%) neonates required renal replacement therapy in the form of peritoneal dialysis. The length of stay was higher in the AKI index group (p = 0.015). Patients who had AKI recovered their kidney function at discharge. There was no difference in mortality between both groups. Conclusion The AKI occurred in 74% of neonates undergoing open-heart surgery, with 23% of them needing peritoneal dialysis. Low pre-operative creatinine, high VIS score, and prolonged bypass time are potential risk factors for AKI development after neonatal open-heart surgery. AKI may lead to prolonged hospitalization, though most affected patients recovered their normal kidney function at discharge.
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Affiliation(s)
- Faisal A. Alghamdi
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
| | | | - Hatim F. Almutairi
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
| | - Nasser S. Alshaiban
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
| | - Khaled E. Alotibi
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
| | - Omar M. Kabbani
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
| | - Mohamed S. Kabbani
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
- King Abdullah International Medical Research Centre (KAIMRC), Riyadh,
Saudi Arabia
- Department of Cardiac Science, Ministry of National Guard Health Affairs, Riyadh,
Saudi Arabia
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2
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Leopoldino RWD, Marques DP, Rocha LC, Fernandes FEM, Oliveira AG, Martins RR. Temporal profile of adverse drug reactions and associated clinical factors: a prospective observational study in a neonatal intensive care unit. BMJ Open 2023; 13:e073304. [PMID: 37553191 PMCID: PMC10414078 DOI: 10.1136/bmjopen-2023-073304] [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] [Received: 03/02/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE Although adverse drug reactions (ADRs) are quite common in hospitalised neonates, pharmacovigilance activities in this public are still incipient. This study aims to characterise ADRs in neonates in a neonatal intensive care unit (NICU), identifying causative drugs, temporal profile and associated factors. DESIGN Prospective observational study. SETTING NICU of a public maternity hospital in Natal/Brazil. PARTICIPANTS All neonates admitted to the NICU for more than 24 hours and using at least one medication were followed up during the time of hospitalisation. PRIMARY OUTCOME MEASURES Incidence rate and risk factors for ADRs. The ADRs were detected by an active search in electronic medical records and analysis of spontaneous reports in the hospital pharmacovigilance system. RESULTS Six hundred neonates were included in the study, where 118 neonates had a total of 186 ADRs. The prevalence of ADRs at the NICU was 19.7% (95% CI 16.7% to 23.0%). The most common ADRs were tachycardia (30.6%), polyuria (9.1%) and hypokalaemia (8.6%). Tachycardia (peak incidence rate: 57.1 ADR/1000 neonates) and hyperthermia (19.1 ADR/1000 neonates) predominated during the first 5 days of hospitalisation. The incidence rate of polyuria and hypokalaemia increased markedly after the 20th day, with both reaching a peak of 120.0 ADR/1000 neonates. Longer hospitalisation time (OR 0.018, 95% CI 0.007 to 0.029; p<0.01) and number of prescribed drugs (OR 0.127, 95% CI 0.075 to 0.178; p<0.01) were factors associated with ADRs. CONCLUSION ADRs are very common in NICU, with tachycardia and hyperthermia predominant in the first week of hospitalisation and polyuria and hypokalaemia from the third week onwards.
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Affiliation(s)
- Ramon Weyler Duarte Leopoldino
- Graduate Program of Pharmaceutical Science, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Daniel Paiva Marques
- Department of Pharmacy, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Luan Carvalho Rocha
- Department of Pharmacy, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Flavia Evelyn Medeiros Fernandes
- School Maternity Januário Cicco (MEJC/EBSERH), Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Antonio Gouveia Oliveira
- Graduate Program of Pharmaceutical Science, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
- Department of Pharmacy, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
| | - Rand Randall Martins
- Graduate Program of Pharmaceutical Science, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
- Department of Pharmacy, Federal University of Rio Grande do Norte, Center for Health Sciences, Natal, Brazil
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3
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Kerling DA, Clarke SC, DeLuca JP, Evans MO, Kress AT, Nadeau RJ, Selig DJ. Systematic Review and Meta-Analysis of the Effect of Loop Diuretics on Antibiotic Pharmacokinetics. Pharmaceutics 2023; 15:pharmaceutics15051411. [PMID: 37242653 DOI: 10.3390/pharmaceutics15051411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/19/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Loop diuretics and antibiotics are commonly co-prescribed across many clinical care settings. Loop diuretics may alter antibiotic pharmacokinetics (PK) via several potential drug interactions. A systematic review of the literature was performed to investigate the impact of loop diuretics on antibiotic PK. The primary outcome metric was the ratio of means (ROM) of antibiotic PK parameters such as area under the curve (AUC) and volume of distribution (Vd) on and off loop diuretics. Twelve crossover studies were amenable for metanalysis. Coadministration of diuretics was associated with a mean 17% increase in plasma antibiotic AUC (ROM 1.17, 95% CI 1.09-1.25, I2 = 0%) and a mean decrease in antibiotic Vd by 11% (ROM 0.89, 95% CI 0.81-0.97, I2 = 0%). However, the half-life was not significantly different (ROM 1.06, 95% CI 0.99-1.13, I2 = 26%). The remaining 13 observational and population PK studies were heterogeneous in design and population, as well as prone to bias. No large trends were collectively observed in these studies. There is currently not enough evidence to support antibiotic dosing changes based on the presence or absence of loop diuretics alone. Further studies designed and powered to detect the effect of loop diuretics on antibiotic PK are warranted in applicable patient populations.
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Affiliation(s)
- David A Kerling
- Walter Reed National Military Medical Center, Internal Medicine, Bethesda, MD 20889, USA
| | - Sarah C Clarke
- Walter Reed National Military Medical Center, Internal Medicine, Bethesda, MD 20889, USA
| | - Jesse P DeLuca
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
| | - Martin O Evans
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
| | - Adrian T Kress
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
| | - Robert J Nadeau
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
| | - Daniel J Selig
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
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4
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Lalitha R, Surak A, Bitar E, Hyderi A, Kumaran K. Fluid and electrolyte management in preterm infants with patent ductus arteriosus. J Neonatal Perinatal Med 2022; 15:689-697. [PMID: 35599502 DOI: 10.3233/npm-210943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Optimal fluid management of preterm babies with suspected or confirmed diagnosis of patent ductus arteriosus (PDA) is frequently challenging for neonatal care physician because of paucity of clinical trials. There is wide variation in practice across neonatal units, resulting in significant impact on outcomes in Extremely Low Birth Weight (ELBW) babies with hemodynamically significant PDA. A delicate balance is required in fluid management to reduce mortality and morbidity in this population. The purpose of this review is to lay out the current understanding about fluid and electrolyte management in ELBW babies with hemodynamically significant PDA and highlight areas for future research.
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Affiliation(s)
- R Lalitha
- Department of Pediatrics, University of Western Ontario, Division of Neonatal-Perinatal Medicine, London, ON, Canada
| | - A Surak
- University of Alberta, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Edmonton, Alberta, Canada
| | - E Bitar
- University of Alberta, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Edmonton, Alberta, Canada
| | - A Hyderi
- University of Alberta, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Edmonton, Alberta, Canada
| | - K Kumaran
- University of Alberta, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Edmonton, Alberta, Canada
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5
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A whole blood microsampling furosemide assay: development, validation and use in a pediatric pharmacokinetic study. Bioanalysis 2022; 14:1025-1038. [PMID: 36165919 PMCID: PMC9540403 DOI: 10.4155/bio-2022-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Furosemide is a commonly used diuretic for the treatment of edema. The pharmacokinetics of furosemide in neonates as they mature remains poorly understood. Microsampling assays facilitate research in pediatric populations. Results: We developed and validated a liquid chromatography-tandem mass spectrometry method for the quantitation of furosemide in human whole blood with volumetric absorptive microsampling (VAMS) devices (10 μl). Furosemide was stable in human whole blood VAMS under the study's assay conditions. This work established stability for furosemide for 161 days when stored as dried microsamples at -78°C. Conclusion: This method is being applied for the quantitation of furosemide in whole blood VAMS in an ongoing prospective pediatric clinical study. Representative clinical data are reported.
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6
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Sridharan K, Al Madhoob A, Al Jufairi M. Cumulative Doses Predict the Risk of Furosemide-Induced Electrolyte Abnormalities in Critically Ill Neonates. Ther Clin Risk Manag 2022; 18:633-641. [PMID: 35707182 PMCID: PMC9191601 DOI: 10.2147/tcrm.s369737] [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: 04/09/2022] [Accepted: 06/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background Furosemide has limited indications in the term neonates. Its use in preterm neonates is off-label. Considering the dearth of data, we carried out a retrospective study evaluating the furosemide use and its effects on the electrolyte abnormalities in critically ill neonates. Methods Critically ill neonates receiving at least one dose of furosemide during their stay in the NICU were recruited. The following details were obtained: demographic characteristics and furosemide details (dose, frequency, route, and duration). Urine output, body weight, serum creatinine, electrolytes (sodium, potassium, calcium, bicarbonate, chloride, and magnesium) during furosemide therapy were extracted. Results Ninety neonates were recruited. Elevated serum creatinine was observed in 21.1% of the patients, and electrolyte disturbances were observed in 52.2%. Those with electrolyte disturbances had significantly greater cumulative doses compared to those without [5.5 (1–34) vs 3.9 (0.9–30.2) mg/kg; p = 0.01]. Cumulative doses adjusted to body-weight were significantly lower in very preterm and extremely preterm neonates compared to late preterm category. A significant area-under-the-curve was observed for the cumulative dose (0.66; 95% CI: 0.54–0.78; p = 0.01) in predicting the risk of electrolyte abnormalities with a cut-off value of 4 mg/kg. Eight neonates received more than 10 mg/kg cumulative dose of furosemide of which one died. No significant differences were observed between the proportion of neonates with electrolyte disturbances with cumulative furosemide dose above 10 mg/kg (p = 0.3) and with mortality (p = 0.3). Conclusion We observed that our critically ill neonates received relatively higher cumulative doses of furosemide and electrolyte disturbances were observed in nearly half of the population. A cumulative dose of 4 mg/kg increases the risk of electrolyte abnormalities, particularly in preterm neonates. More diligence in the dose titration coupled with deprescribing and intense monitoring of all the potential adverse effects in this vulnerable population is needed.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | | | - Muna Al Jufairi
- Neonatal Intensive Care Unit, Salmaniya Medical Complex, Manama, Kingdom of Bahrain.,Department of Pediatrics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
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7
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Bruschettini M, Hassan KO, Romantsik O, Banzi R, Calevo MG, Moresco L. Interventions for the management of transient tachypnoea of the newborn - an overview of systematic reviews. Cochrane Database Syst Rev 2022; 2:CD013563. [PMID: 35199848 PMCID: PMC8867535 DOI: 10.1002/14651858.cd013563.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Transient tachypnoea of the newborn (TTN) is characterised by tachypnoea and signs of respiratory distress. It is caused by delayed clearance of lung fluid at birth. TTN typically appears within the first two hours of life in term and late preterm newborns. Although it is usually a self-limited condition, admission to a neonatal unit is frequently required for monitoring, the provision of respiratory support, and drugs administration. These interventions might reduce respiratory distress during TTN and enhance the clearance of lung liquid. The goals are reducing the effort required to breathe, improving respiratory distress, and potentially shortening the duration of tachypnoea. However, these interventions might be associated with harm in the infant. OBJECTIVES The aim of this overview was to evaluate the benefits and harms of different interventions used in the management of TTN. METHODS We searched the Cochrane Database of Systematic Reviews on 14 July 2021 for ongoing and published Cochrane Reviews on the management of TTN in term (> 37 weeks' gestation) or late preterm (34 to 36 weeks' gestation) infants. We included all published Cochrane Reviews assessing the following categories of interventions administered within the first 48 hours of life: beta-agonists (e.g. salbutamol and epinephrine), corticosteroids, diuretics, fluid restriction, and non-invasive respiratory support. The reviews compared the above-mentioned interventions to placebo, no treatment, or other interventions for the management of TTN. The primary outcomes of this overview were duration of tachypnoea and the need for mechanical ventilation. Two overview authors independently checked the eligibility of the reviews retrieved by the search and extracted data from the included reviews using a predefined data extraction form. Any disagreements were resolved by discussion with a third overview author. Two overview authors independently assessed the methodological quality of the included reviews using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) tool. We used the GRADE approach to assess the certainty of evidence for effects of interventions for TTN management. As all of the included reviews reported summary of findings tables, we extracted the information already available and re-graded the certainty of evidence of the two primary outcomes to ensure a homogeneous assessment. We provided a narrative summary of the methods and results of each of the included reviews and summarised this information using tables and figures. MAIN RESULTS We included six Cochrane Reviews, corresponding to 1134 infants enrolled in 18 trials, on the management of TTN in term and late preterm infants, assessing salbutamol (seven trials), epinephrine (one trial), budesonide (one trial), diuretics (two trials), fluid restriction (four trials), and non-invasive respiratory support (three trials). The quality of the included reviews was high, with all of them fulfilling the critical domains of the AMSTAR 2. The certainty of the evidence was very low for the primary outcomes, due to the imprecision of the estimates (few, small included studies) and unclear or high risk of bias. Salbutamol may reduce the duration of tachypnoea compared to placebo (mean difference (MD) -16.83 hours, 95% confidence interval (CI) -22.42 to -11.23, 2 studies, 120 infants, low certainty evidence). We did not identify any review that compared epinephrine or corticosteroids to placebo and reported on the duration of tachypnoea. However, one review reported on "trend of normalisation of respiratory rate", a similar outcome, and found no differences between epinephrine and placebo (effect size not reported). The evidence is very uncertain regarding the effect of diuretics compared to placebo (MD -1.28 hours, 95% CI -13.0 to 10.45, 2 studies, 100 infants, very low certainty evidence). We did not identify any review that compared fluid restriction to standard fluid rates and reported on the duration of tachypnoea. The evidence is very uncertain regarding the effect of continuous positive airway pressure (CPAP) compared to free-flow oxygen therapy (MD -21.1 hours, 95% CI -22.9 to -19.3, 1 study, 64 infants, very low certainty evidence); the effect of nasal high-frequency (oscillation) ventilation (NHFV) compared to CPAP (MD -4.53 hours, 95% CI -5.64 to -3.42, 1 study, 40 infants, very low certainty evidence); and the effect of nasal intermittent positive pressure ventilation (NIPPV) compared to CPAP on duration of tachypnoea (MD 4.30 hours, 95% CI -19.14 to 27.74, 1 study, 40 infants, very low certainty evidence). Regarding the need for mechanical ventilation, the evidence is very uncertain for the effect of salbutamol compared to placebo (risk ratio (RR) 0.60, 95% CI 0.13 to 2.86, risk difference (RD) 10 fewer, 95% CI 50 fewer to 30 more per 1000, 3 studies, 254 infants, very low certainty evidence); the effect of epinephrine compared to placebo (RR 0.67, 95% CI 0.08 to 5.88, RD 70 fewer, 95% CI 460 fewer to 320 more per 1000, 1 study, 20 infants, very low certainty evidence); and the effect of corticosteroids compared to placebo (RR 0.52, 95% CI 0.05 to 5.38, RD 40 fewer, 95% CI 170 fewer to 90 more per 1000, 1 study, 49 infants, very low certainty evidence). We did not identify a review that compared diuretics to placebo and reported on the need for mechanical ventilation. The evidence is very uncertain regarding the effect of fluid restriction compared to standard fluid administration (RR 0.73, 95% CI 0.24 to 2.23, RD 20 fewer, 95% CI 70 fewer to 40 more per 1000, 3 studies, 242 infants, very low certainty evidence); the effect of CPAP compared to free-flow oxygen (RR 0.30, 95% CI 0.01 to 6.99, RD 30 fewer, 95% CI 120 fewer to 50 more per 1000, 1 study, 64 infants, very low certainty evidence); the effect of NIPPV compared to CPAP (RR 4.00, 95% CI 0.49 to 32.72, RD 150 more, 95% CI 50 fewer to 350 more per 1000, 1 study, 40 infants, very low certainty evidence); and the effect of NHFV versus CPAP (effect not estimable, 1 study, 40 infants, very low certainty evidence). Regarding our secondary outcomes, duration of hospital stay was the only outcome reported in all of the included reviews. One trial on fluid restriction reported a lower duration of hospitalisation in the restricted-fluids group, but with very low certainty of evidence. The evidence was very uncertain for the effects on secondary outcomes for the other five reviews. Data on potential harms were scarce, as all of the trials were underpowered to detect possible increases in adverse events such as pneumothorax, arrhythmias, and electrolyte imbalances. No adverse effects were reported for salbutamol; however, this medication is known to carry a risk of tachycardia, tremor, and hypokalaemia in other settings. AUTHORS' CONCLUSIONS This overview summarises the evidence from six Cochrane Reviews of randomised trials regarding the effects of postnatal interventions in the management of TTN. Salbutamol may reduce the duration of tachypnoea slightly. We are uncertain as to whether salbutamol reduces the need for mechanical ventilation. We are uncertain whether epinephrine, corticosteroids, diuretics, fluid restriction, or non-invasive respiratory support reduces the duration of tachypnoea and the need for mechanical ventilation, due to the extremely limited evidence available. Data on harms were lacking.
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Affiliation(s)
- Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
| | - Rita Banzi
- Center for Health Regulatory Policies, Mario Negri Institute for Pharmacological Research IRCCS, Milan, Italy
| | - Maria Grazia Calevo
- Epidemiology, Biostatistics Unit, IRCCS, Istituto Giannina Gaslini, Genoa, Italy
| | - Luca Moresco
- Pediatric and Neonatology Unit, Ospedale San Paolo, Savona, Italy
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8
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Williams EE, Gunawardana S, Donaldson NK, Dassios T, Greenough A. Postnatal diuretics, weight gain and home oxygen requirement in extremely preterm infants. J Perinat Med 2022; 50:100-107. [PMID: 34265878 DOI: 10.1515/jpm-2021-0256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/25/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Diuretics are often given to infants with evolving/established bronchopulmonary dysplasia (BPD) with the hope of improving their pulmonary outcomes. We aimed to determine if diuretic use in preterm infants was associated with improved pulmonary outcomes, but poorer weight gain. METHODS An observational study over a 5 year period was undertaken of all infants born at less than 29 weeks of gestation and alive at discharge in all neonatal units in England who received consecutive diuretic use for at least 7 days. Postnatal weight gain and home supplementary oxygen requirement were the outcomes. A literature review of randomised controlled trials (RCTs) and crossover studies was undertaken to determine if diuretic usage was associated with changes in lung mechanics and oxygenation, duration of supplementary oxygen and requirement for home supplementary oxygen. RESULTS In the observational study, 9,457 infants survived to discharge, 44.6% received diuretics for at least 7 days. Diuretic use was associated with an increased probability of supplementary home oxygen of 0.14 and an increase in weight gain of 2.5 g/week. In the review, seven of the 10 studies reported improvements only in short term lung mechanics. There was conflicting evidence regarding whether diuretics resulted in short term improvements in oxygenation. CONCLUSIONS Diuretic use was not associated with a reduction in requirement for supplemental oxygen on discharge. The literature review highlighted a lack of RCTs assessing meaningful long-term clinical outcomes. Randomised trials are needed to determine the long-term risk benefit ratio of chronic diuretic use.
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Affiliation(s)
- Emma E Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Shannon Gunawardana
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK.,Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.,National Institute for Health Research (NIHR), Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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9
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Okazaki K, Fukuoka N, Kuboi T, Unemoto J, Kondo M, Kusaka T, Itoh S. Furosemide clearance in very preterm neonates early in life: A pilot study using scavenged samples. Pediatr Int 2022; 64:e14735. [PMID: 33848384 DOI: 10.1111/ped.14735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 04/03/2021] [Accepted: 04/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Furosemide is an off-label drug, frequently used as a diuretic in neonates with oliguria and/or edema. Its clearance in preterm neonates is lower than in term neonates or children. We aimed, herein, to clarify furosemide clearance (CL) in very preterm (VP) neonates (<28 weeks' gestation) within the first 2 weeks of life and identify the factors predictive of the pharmacokinetics (PK) parameters, such as CL. METHODS Furosemide was administered at 0.5 or 1 mg/kg in a 0.5-h infusion via a syringe pump; blood samples were drawn from an artery or vein after the intravenous injection. The serum furosemide concentration was measured using high-performance liquid chromatography. The PK parameters were then analyzed using Bayesian estimation. RESULTS Thirteen blood samples were obtained from 10 VP neonates after intravenous injection. The mean postconceptional age and mean postnatal days at exposure to furosemide were 26.9 weeks and 7.1 days, respectively. The estimated mean CL was 16.5 mL/kg/h. The mean distribution volume (Vd) and elimination half-life (t1/2) were 0.37 L/kg and 15.3 h, respectively. Furosemide CL was negatively associated with serum creatinine (SCr) [CL = 84.2 - 67.1 × SCr (mg/dL)]. CONCLUSIONS Very preterm neonates within the first 2 weeks of life had a higher CL than subjects in other preterm neonatal studies. The SCr level was the sole parameter influencing furosemide CL and might serve as a good index for furosemide dosing in VP neonates.
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Affiliation(s)
- Kaoru Okazaki
- Department of Neonatology, Shikoku Medical Center for Children and Adults, Kagawa, Japan.,Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Noriyasu Fukuoka
- Laboratory of Hospital Pharmacy, School of Pharmacy, Nihon University, Chiba, Japan
| | - Toru Kuboi
- Department of Neonatology, Shikoku Medical Center for Children and Adults, Kagawa, Japan
| | - Jun Unemoto
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masatoshi Kondo
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Kagawa University, Kagawa, Japan
| | - Susumu Itoh
- Department of Pediatrics, Kagawa University, Kagawa, Japan
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10
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Rhoads E, Montgomery GS, Ren CL. Wheezing in preterm infants and children. Pediatr Pulmonol 2021; 56:3472-3477. [PMID: 33580622 DOI: 10.1002/ppul.25314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/23/2021] [Accepted: 02/08/2021] [Indexed: 11/10/2022]
Abstract
Wheezing is a common outcome of preterm birth. This article will review the mechanisms, epidemiology, and treatment of wheezing in preterm children with and without a history of bronchopulmonary dysplasia.
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Affiliation(s)
- Eli Rhoads
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gregory S Montgomery
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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11
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Guignard JP, Iacobelli S. Use of diuretics in the neonatal period. Pediatr Nephrol 2021; 36:2687-2695. [PMID: 33481099 DOI: 10.1007/s00467-021-04921-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/06/2020] [Accepted: 01/05/2021] [Indexed: 12/31/2022]
Abstract
The use of diuretics is extremely frequent in sick neonates, the more so in very premature newborn infants. The use of diuretics in patients whose kidney function is immature necessitates a thorough knowledge of renal developmental physiology and pathophysiology. This review presents the basic aspects of body fluid homeostasis in the neonate, discusses the development of kidney function, and describes the mechanisms involved in electrolyte and water reabsorption along the nephron. Diuretics are then classified according to the site of their action on sodium reabsorption. The use of diuretics in sodium-retaining states, in oliguric states, in electrolyte disorders, and in arterial hypertension, as well as in a few specific disorders, is presented. Common and specific adverse effects are discussed. Recommended dosages for the main diuretics used in the neonatal period are given. New developments in diuretic therapy are briefly mentioned.
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Affiliation(s)
| | - Silvia Iacobelli
- Néonatologie, Réanimation Néonatale et Pédiatrique, CHU La Réunion, Site Sud, Saint Pierre, France. .,Centre d'Etudes Périnatales de l'Océan Indien, CHU La Réunion, Saint Pierre et Université de la Réunion, Site Sud, EA 7388, Saint Pierre, France.
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12
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Cetin G, Corum O, Durna Corum D, Atik O, Turk E, Tekeli IO, Uney K. Pharmacokinetics of furosemide in goats following intravenous, intramuscular, and subcutaneous administrations. J Vet Pharmacol Ther 2021; 44:961-966. [PMID: 34427339 DOI: 10.1111/jvp.13009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/02/2021] [Accepted: 07/18/2021] [Indexed: 11/30/2022]
Abstract
Furosemide, a loop diuretic drug, is recommended for use in cases of edema, ascites, congestive heart failure, toxicosis, and acute renal failure in goats. However, its pharmacokinetics and bioavailability have not been reported yet in this species. The aim of this study was to determine the pharmacokinetics and bioavailability of furosemide in goats following intravenous (IV), intramuscular (IM), and subcutaneous (SC) administrations at a dose of 2.5 mg/kg. Six clinically healthy goats received furosemide by each route in a three-way crossover pharmacokinetic design with a 15-day washout period between administrations. The plasma concentrations of furosemide were determined using the high-performance liquid chromatography-UV method and analyzed by non-compartmental analysis. The elimination half-life following IV, IM, and SC administration was 0.71 (0.67-0.76) h, 0.69 (0.61-0.74) h, and 0.70 (0.67-0.79) h, respectively. The volume of distribution at steady state and total clearance for the IV route were 0.17 (0.16-0.19) L/kg and 0.30 (0.27-0.33) L/h/kg, respectively. The peak plasma concentrations of furosemide following IM and SC administrations were 11.19 (10.33-11.95) and 6.49 (5.92-7.00) μg/ml at 0.23 (0.16-0.25) and 0.39 (0.33-0.42) h, respectively. The bioavailability was 109.84 (104.92-116.99)% and 70.80 (55.77-86.67)% for the IM and SC routes, respectively. The pharmacokinetics of furosemide following the IV, IM, and SC administrations in goats demonstrated significant differences, which may have clinical and toxicological implications requiring further investigations.
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Affiliation(s)
- Gul Cetin
- Department of Pharmacology, Faculty of Pharmacy, University of Erzincan Binali Yıldırım, Erzincan, Turkey
| | - Orhan Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - Duygu Durna Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - Orkun Atik
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Afyon Kocatepe, Afyonkarahisar, Turkey
| | - Erdinc Turk
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Hatay Mustafa Kemal, Hatay, Turkey
| | - Ibrahim Ozan Tekeli
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Hatay Mustafa Kemal, Hatay, Turkey
| | - Kamil Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
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13
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Muehlbacher T, Bassler D, Bryant MB. Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants. CHILDREN-BASEL 2021; 8:children8040298. [PMID: 33924638 PMCID: PMC8069828 DOI: 10.3390/children8040298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/15/2022]
Abstract
Background: Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. Objective: The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD. Methods: We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy. Results: Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review. Discussion: There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only.
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14
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Formulation and in vitro evaluation of self-nanoemulsifying liquisolid tablets of furosemide. Sci Rep 2021; 11:1315. [PMID: 33446749 PMCID: PMC7809212 DOI: 10.1038/s41598-020-79940-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022] Open
Abstract
Self-nanoemulsifying drug delivery systems (SNEDDS) were used to enhance the dissolution rate of furosemide as a model for class IV drugs and the system was solidified into liquisolid tablets. SNEDDS of furosemide contained 10% Castor oil, 60% Cremophor EL, and 30% PEG 400. The mean droplets size was 17.9 ± 4.5 nm. The theoretical model was used to calculate the amounts of the carrier (Avicel PH101) and coating materials (Aerosil 200) to prepare liquisolid powder. Carrier/coating materials ratio of 5/1 was used and Ludipress was added to the solid system, thus tablets with hardness of 45 ± 2 N were obtained. Liquisolid tablets showed 2-folds increase in drug release as compared to the generic tablets after 60 min in HCl 0.1 N using USP apparatus-II. Furosemide loaded SNEDDS tablets have great prospects for further in vivo studies, and the theoretical model is useful for calculating the adequate amounts of adsorbents required to solidify these systems.
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15
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Salerno SN, Liao Y, Jackson W, Greenberg RG, McKinzie CJ, McCallister A, Benjamin DK, Laughon MM, Sanderson K, Clark RH, Gonzalez D. Association between Nephrotoxic Drug Combinations and Acute Kidney Injury in the Neonatal Intensive Care Unit. J Pediatr 2021; 228:213-219. [PMID: 32818481 PMCID: PMC7752849 DOI: 10.1016/j.jpeds.2020.08.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine the incidence of acute kidney injury (AKI) in infants exposed to nephrotoxic drug combinations admitted to 268 neonatal intensive care units managed by the Pediatrix Medical Group. STUDY DESIGN We included infants born at 22-36 weeks gestational age, ≤120 days postnatal age, exposed to nephrotoxic drug combinations, with serum creatinine measurements available, and discharged between 2007 and 2016. To identify risk factors associated with a serum creatinine definition of AKI based on the Kidney Disease: Improving Global Outcomes criteria, we performed multivariable logistic and Cox regression adjusting for gestational age, sex, birth weight, postnatal age, race/ethnicity, sepsis, respiratory distress syndrome, baseline serum creatinine, and duration of combination drug exposure. The adjusted odds of AKI were determined relative to gentamicin + indomethacin for the following nephrotoxic drug combinations: chlorothiazide + ibuprofen; chlorothiazide + indomethacin; furosemide + gentamicin; furosemide + ibuprofen; furosemide + tobramycin; ibuprofen + spironolactone; and vancomycin + piperacillin-tazobactam. RESULTS Among 8286 included infants, 1384 (17%) experienced AKI. On multivariable analysis, sepsis, lower baseline creatinine, and duration of combination therapy were associated with increased odds of AKI. Furosemide + tobramycin and vancomycin + piperacillin-tazobactam were associated with a decreased risk of AKI relative to gentamicin + indomethacin in both the multivariable and Cox regression models. CONCLUSIONS In this cohort, infants receiving longer durations of nephrotoxic combination therapy had an increased odds of developing AKI.
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Affiliation(s)
- Sara N. Salerno
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yuting Liao
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Wesley Jackson
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA
| | - Cameron J. McKinzie
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Ashley McCallister
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | | | - Matthew M. Laughon
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keia Sanderson
- Department of Medicine-Nephrology, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Reese H. Clark
- MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
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16
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Hanna RM, Ahdoot RS, Kalantar-Zadeh K, Ghobry L, Kurtz I. Calcium Transport in the Kidney and Disease Processes. Front Endocrinol (Lausanne) 2021; 12:762130. [PMID: 35299844 PMCID: PMC8922474 DOI: 10.3389/fendo.2021.762130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/25/2021] [Indexed: 11/25/2022] Open
Abstract
Calcium is a key ion involved in cardiac and skeletal muscle contractility, nerve function, and skeletal structure. Global calcium balance is affected by parathyroid hormone and vitamin D, and calcium is shuttled between the extracellular space and the bone matrix compartment dynamically. The kidney plays an important role in whole-body calcium balance. Abnormalities in the kidney transport proteins alter the renal excretion of calcium. Various hormonal and regulatory pathways have evolved that regulate the renal handling of calcium to maintain the serum calcium within defined limits despite dynamic changes in dietary calcium intake. Dysregulation of renal calcium transport can occur pharmacologically, hormonally, and via genetic mutations in key proteins in various nephron segments resulting in several disease processes. This review focuses on the regulation transport of calcium in the nephron. Genetic diseases affecting the renal handling of calcium that can potentially lead to changes in the serum calcium concentration are reviewed.
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Affiliation(s)
- Ramy M. Hanna
- Division of Nephrology, Department of Medicine, University of California Irvine (UCI) School of Medicine, Orange, CA, United States
- *Correspondence: Ramy M. Hanna,
| | - Rebecca S. Ahdoot
- Division of Nephrology, Department of Medicine, University of California Irvine (UCI) School of Medicine, Orange, CA, United States
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Department of Medicine, University of California Irvine (UCI) School of Medicine, Orange, CA, United States
| | - Lena Ghobry
- School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ira Kurtz
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, United States
- University of California Los Angeles (UCLA) Brain Research Center, Los Angeles, CA, United States
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17
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Durna Corum D, Corum O, Atik O, Cetin G, Zhunushova A, Uney K. Pharmacokinetics and bioavailability of furosemide in sheep. J Vet Pharmacol Ther 2020; 44:657-662. [PMID: 33314204 DOI: 10.1111/jvp.12937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/10/2020] [Accepted: 11/23/2020] [Indexed: 11/29/2022]
Abstract
The pharmacokinetics and bioavailability of furosemide were determined following intravenous (IV), intramuscular (IM), and subcutaneous (SC) administrations at 2.5 mg/kg dose in sheep. The study was conducted on six healthy sheep in a three-way, three-period, crossover pharmacokinetic design with a 15-day washout period. In first period, furosemide was randomly administered via IV to 2 sheep, IM to 2 sheep and SC to 2 sheep. In second and third periods, each sheep received furosemide via different routes of administration with the 15-day washout period. Plasma concentrations were determined using a high-performance liquid chromatography assay and analyzed by noncompartmental method. The mean total clearance and volume of distribution at steady state following IV administration were 0.24 L h-1 kg-1 and 0.17 L/kg, respectively. The elimination half-life was similar for all administration routes. The mean peak plasma concentrations of IM and SC administration were 10.33 and 3.18 μg/ml at 0.33 and 0.42 hr, respectively. The mean bioavailability of IM and SC administration was 97.91% and 37.98%, respectively. The IM injection of furosemide may be the alternative routes in addition to IV. However, further research is required to determine the effect of dose and route of administration on the clinical efficacy of furosemide in sheep.
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Affiliation(s)
- Duygu Durna Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - Orhan Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - Orkun Atik
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Afyon Kocatepe, Afyonkarahisar, Turkey
| | - Gul Cetin
- Department of Pharmacology, Faculty of Pharmacy, University of Erzincan Binali Yıldırım, Erzincan, Turkey
| | - Aidai Zhunushova
- Faculty of Veterinary Medicine, University of Kyrgyz-Turkish Manas, Bishkek, Kyrgyzstan.,Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
| | - Kamil Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
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18
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Ghaysouri A, Basati G, Shams M, Tavan H. Efficiency of Nebulizing Furosemide in the Treatment of Chronic Pulmonary Obstructive Disease: A Systematic Review and Meta-Analysis of Clinical Trials. TANAFFOS 2020; 19:340-349. [PMID: 33959171 PMCID: PMC8088148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is one of the most common chronic illnesses in humans. Among both oral and intravenous diuretics, nebulizing furosemide (Lasix) is the most commonly used agent. The purpose of this study was to ascertain the therapeutic effects of nebulizing furosemide compared with placebo in the treatment of COPD using a systematic review and meta-analysis of clinical trials. MATERIALS AND METHODS This review was performed based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol. The databases of Web of Science, Google Scholar, PubMed, and Scopus were independently searched by two researchers using MeSH keywords. Studies published between 2002 and 2018 in different parts of the world were considered. The meta-analysis was performed through STATA 14 software and the heterogeneity was assessed using Q statistic or I2 index. RESULTS From 40 selected articles, 8 articles were finally included in the systematic review process. The analyses were performed considering two groups; nebulizing furosemide treatment (i.e. case) and placebo (i.e. control). Based on the forest plots, the average values of PaCO2 were 48.3 (39.04-57.56) and 46.56 (39.94-53.18) in the case and control groups, respectively. Also, the mean forced expiratory volume in the first second (FEV1) was 49 (31.32-66.67) and 46.87 (31.44-62.30) in the case and control groups, respectively. Meta-regression analysis showed that both heart and pulse rates in the nebulizing furosemide group decreased by increasing the year of study and sample size (P <0.001). The heterogeneity among the studies was found to be 72.2%, which is classified as severe heterogeneity. CONCLUSION nebulizing furosemide can improve and normalize the vital signs and other respiratory variables in patients with COPD.
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Affiliation(s)
- Abas Ghaysouri
- Department of Internal Medicine, School of Medicine, Shahid Mostafa Khomaeini Hospital, Ilam University of Medical Sciences, Ilam, Iran
| | - Gholam Basati
- School of Allied Medical Sciences, Zoonotic Diseases Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Morteza Shams
- Zoonotic Diseases Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Hamed Tavan
- Clinical Research Development Unit, Shahid Mostafa Khomeini Hospital, Ilam University of Medical Sciences, Ilam, Iran.,Correspondence to: Tavan H Address: Clinical Research Development Unit, Shahid Mostafa Khomeini Hospital, Ilam University of Medical Sciences, Ilam, Iran Email address:
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19
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Shi Z, Wu J, Song Q, Göstl R, Herrmann A. Toward Drug Release Using Polymer Mechanochemical Disulfide Scission. J Am Chem Soc 2020; 142:14725-14732. [PMID: 32804498 DOI: 10.1021/jacs.0c07077] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Traditional pharmacotherapy suffers from multiple drawbacks that hamper patient treatment, such as the buildup of antibiotic resistances or low drug selectivity and toxicity during systemic application. To overcome these challenges, drug activity can be controlled by employing delivery, targeting, or release solutions that mostly rely on the response to external physicochemical stimuli. Due to various technical limitations, mechanical force as a stimulus in the context of polymer mechanochemistry has so far not been used for this purpose, yet it has been proven to be a convenient and robust method to site-selectively rearrange or cleave bonds with submolecular precision in the realm of materials chemistry. Here, we present an unprecedented mechanochemically responsive system capable of successively releasing small furan-containing molecules, including the furylated fluorophore dansyl and the drugs furosemide as well as furylated doxorubicin, by ultrasound-induced selective scission of disulfide-centered polymers in solution. We show that mechanochemically generated thiol-terminated polymers undergo a Michael-type addition to Diels-Alder (DA) adducts of furylated drugs and acetylenedicarboxylate derivatives, initiating the downstream release of the small molecule drug by a retro DA reaction. We believe that this method can serve as a blueprint for the activation of many other small molecules.
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Affiliation(s)
- Zhiyuan Shi
- DWI - Leibniz Institute for Interactive Materials, Forckenbeckstr. 50, 52056 Aachen, Germany.,Institute of Technical and Macromolecular Chemistry, RWTH Aachen University, Worringerweg 1, 52074 Aachen, Germany
| | - Jingnan Wu
- DWI - Leibniz Institute for Interactive Materials, Forckenbeckstr. 50, 52056 Aachen, Germany.,Institute of Technical and Macromolecular Chemistry, RWTH Aachen University, Worringerweg 1, 52074 Aachen, Germany
| | - Qingchuan Song
- DWI - Leibniz Institute for Interactive Materials, Forckenbeckstr. 50, 52056 Aachen, Germany.,Institute of Technical and Macromolecular Chemistry, RWTH Aachen University, Worringerweg 1, 52074 Aachen, Germany
| | - Robert Göstl
- DWI - Leibniz Institute for Interactive Materials, Forckenbeckstr. 50, 52056 Aachen, Germany
| | - Andreas Herrmann
- DWI - Leibniz Institute for Interactive Materials, Forckenbeckstr. 50, 52056 Aachen, Germany.,Institute of Technical and Macromolecular Chemistry, RWTH Aachen University, Worringerweg 1, 52074 Aachen, Germany.,Zernike Institute for Advanced Materials, University of Groningen, Nijenborgh 4, 9747 AG Groningen, The Netherlands
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20
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Mohammed AK, Madkour MA, Hassanien HM. Furosemide: Would it help to improve the lungs as evaluated by sonography and compliance during aortic coarctation surgery. Ann Card Anaesth 2020; 22:254-259. [PMID: 31274485 PMCID: PMC6639874 DOI: 10.4103/aca.aca_55_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background We evaluated furosemide on attenuating lung injury and/or edema during coarctation repair surgery. We evaluated dynamic lung compliance. We measured the degree of lung edema by means of lung ultrasound (LUS). We recorded the (PaO2/FiO2ratio) as an indicator for oxygenation. Materials and Methods A study was conducted on 56 patients. Patients were divided into two groups: control group (Group C) which did not receive furosemide and furosemide group (Group F) at a dose of 1 mg/kg at induction of anesthesia. Dynamic lung compliance was calculated at induction (Cdyn 1) and at the end of the surgery (Cdyn 2). The (PaO2/FiO2ratio) was calculated at start and end of surgery as (PF 1) and (PF 2), respectively. LUS was performed after induction (LUS 1) and at the end of the surgery. LUS 2 using the 12 regions method plotting the results on scale from 0 to 36. Mechanical ventilation days were recorded. Results Administering furosemide attenuated the lung injury/edema and other pulmonary complications. Furosemide administration improved the dynamic lung compliance in the F Group compared to the C Group. Furthermore, it increased the (PaO2/FiO2ratio) in the F Group compared to the C Group. LUS scale values were lower in the F Group compared to the C Group. There was also less postoperative mechanical ventilation days. Conclusions The use of furosemide was accompanied by improved lung injury/edema profile as indicated by a much less drop in dynamic lung compliance, better oxygenation, a more favorable LUS scale with less parenchymal lung affection.
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Affiliation(s)
- Ahmed Kareem Mohammed
- Department of Anesthesia, Surgical Intensive Care and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mai A Madkour
- Department of Anesthesia, Surgical Intensive Care and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hossam M Hassanien
- Department of Cardiothoracic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
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21
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Manfredini VA, Cerini C, Clavenna A, Dotta A, Caccamo ML, Staffler A, Massenzi L, Rezzonico RM. Furosemide use in Italian neonatal intensive care units: a national survey. Ital J Pediatr 2020; 46:86. [PMID: 32571386 PMCID: PMC7310123 DOI: 10.1186/s13052-020-00851-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/15/2020] [Indexed: 01/30/2023] Open
Abstract
Abstract Background Furosemide is approved in full term neonates to treat edema associated with congestive heart failure, cirrhosis and renal diseases. It is often administered off-label in premature neonates, to treat respiratory conditions and at doses greater-than-recommended. We conducted a national survey on behalf of the Neonatal Pharmacotherapy Study Group of the Italian Society of Neonatology (SIN), to investigate its use in Italian neonatal intensive care units (NICUs), in conformity with current guidelines. Methods Between December 2016 and June 2017, a 14-item multiple-choice online questionnaire was sent to all NICU directors from the SIN directory. Gestational age, route of administration, posology, indications, referenced guidelines, adverse effects monitoring and the presence of Paediatric Cardiology or Cardiosurgery service on site were assessed. A chi-square test was performed 1) to evaluate differences in the distribution of responses between NICUs administering furosemide at doses higher-than-recommended; 2) to compare the proportion of NICUs administering furosemide at high doses in institutions with versus without a Paediatric Cardiology or Cardiosurgery service. Results The response rate was 50% (57/114). The intravenous and oral routes were chosen primarily; the intravenous administration in single doses predominated over continuous infusion. Its main therapeutic indications were congestive heart failure/overload (94.7%) and oligo-anuria (87.7%) however furosemide was also frequently used for broncopulmonary dysplasia (50.9%) and respiratory distress syndrome and/or transient tachypnea of the newborn (24.6%). In 28/57 NICUs furosemide was administered at doses higher-than-recommended. In most NICUs the same posology was used in term and preterm neonates. Compared to the total sample, a larger proportion of NICUs administering doses greater-than-recommended referenced current literature for reasons to do so (19.3 and 32.1% respectively). The presence of a Paediatric Cardiology or Cardiosurgery service on site did not correlate with the chosen posology. The majority of NICUs performed acoustic test and renal ultrasound for furosemide exposure greater than 2 weeks. Conclusions In Italian NICUs, furosemide is commonly prescribed to term and preterm newborns for label and unlabeled indications. Doses greater-than-recommended are frequently administered. Such use is not necessarily inappropriate. More research is required to assess the efficacy and safety of unlabeled use.
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Affiliation(s)
| | - Chiara Cerini
- Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, USA
| | - Antonio Clavenna
- Department of Public Health, Laboratory for Mother and Child Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Andrea Dotta
- Department of Medical and Surgical Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Maria Letizia Caccamo
- Indipedent researcher, Former director of Neonatal Intensive Care Unit, Sant'Anna Hospital, Como, Italy
| | - Alex Staffler
- Division of Neonatology, Central teaching Hospital of Bolzano, Bozen, Italy
| | - Luca Massenzi
- Neonatology and Neonatal Intensive Care Unit, "San Giovanni Calibita" Fatebenefratelli Hospital, Rome, Italy
| | - Rossano Massimo Rezzonico
- Indipendent researcher, Former director of Neonatal Intensive Care Unit, ASST Rhodense, Via C. Forlanini 95, 20024, Milan, Italy
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Vlachou M, Siamidi A, Dotsikas Y. Utilization of a Single Experimental Design for the Optimization of Furosemide Modified-Release Tablet Formulations. Curr Drug Deliv 2020; 16:931-939. [PMID: 31663479 DOI: 10.2174/1567201816666191029130324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 09/11/2019] [Accepted: 10/15/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The loop diuretic drug furosemide is widely used for the treatment of edema in various conditions, such as pulmonary, cardiac and hepatic edema, as well as cardiac infarction. Furosemide, due to its poor water solubility and low bioavailability after oral administration of conventional dosage form, is categorized as class IV in the biopharmaceutical classification system. OBJECTIVE In the case of furosemide, this release profile is responsible for various physiological problems, acute diuresis being the most serious. This adverse effect can be circumvented by the modified release of furosemide from tablet formulations compared to those forms designed for immediate release. METHODS In this report, a D-optimal combined experimental design was applied for the development of furosemide containing bilayer and compression coated tablets, aiming at lowering the drug's burst release in the acidic environment of the stomach. A D-optimal combined design was selected in order to include all requirements in one design with many levels for the factors examined. The following responses were selected as the ones reflecting better criteria for the desired drug release: dissolution at 120 min (30-40%), 300 min (60-70%) and 480 min >95%. The new formulations, suggested by the Doptimal combined design, incorporated different grades of Eudragit ® polymers (Eudragit® E100 and Eudragit® L100-55), lactose monohydrate and HPMC K15M. The dissolution profile of furosemide from these systems was probed via in vitro dissolution experiments in buffer solutions simulating the pH of the gastrointestinal tract. RESULTS The results indicate that the use of Eudragit® E100 in conjunction with lactose monohydrate led to 21.32-40.85 % drug release, in the gastric medium, in both compression-coated and bilayer tablets. This is lower than the release of the mainstream drug Lasix® (t=120 min, 44.5% drug release), implying longer gastric retention and drug waste minimization. CONCLUSION Furosemide's release in the intestinal environment, from compression coated tablets incorporating Eudragit® L100-55 and HPMC K15M in the inner core or one of the two layers of the bilayer tablets, was delayed, compared to Lasix®.
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Affiliation(s)
- Marilena Vlachou
- Section of Pharmaceutical Technology, School of Health Sciences, National and Kapodistrian University of Athens, Athens 15784, Greece
| | - Angeliki Siamidi
- Section of Pharmaceutical Technology, School of Health Sciences, National and Kapodistrian University of Athens, Athens 15784, Greece
| | - Yannis Dotsikas
- Section of Pharmaceutical Chemistry, Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens 15784, Greece
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Modified release of furosemide from Eudragits® and poly(ethylene oxide)-based matrices and dry-coated tablets. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2020; 70:49-61. [PMID: 31677367 DOI: 10.2478/acph-2020-0010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2019] [Indexed: 01/19/2023]
Abstract
Modified release of furosemide from tablet formulations is preferred by patients, because of physiological problems, acute diuresis being the most serious, compared to the forms designed for immediate release. With this in view, we aimed at achieving furosemide's longer gastric retention and waste minimization by preparing matrix and compression coated tablets incorporating different grades of Eudragit® and poly(ethylene oxide) (PEO), polyvinylpyrrolidone (PVP) and lactose monohydrate. Dissolution profiles of the new formulations were compared with that of the main stream drug Lasix®, 40 mg tablets. The results indicate that the use of Eudragit® in conjunction with either PVP or lactose monohydrate led to a slower release rate in the intestinal fluids compared to Lasix®. Moreover, furosemide release in the intestinal pH from matrix tablets and compression coated tablets was not noticeably different. Formulations incorporating PEO led to sustained release, in intestinal fluids, which depended on the molecular weight of PEO.
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Pettit KA, Schreiter NA, Lushaj EB, Hermsen JL, Wilhelm M, Mahon ACR, Nelson KL, DeGrave JJ, Marka N, Anagnostopoulos PV. Prophylactic Peritoneal Drainage is Associated with Improved Fluid Output after Congenital Heart Surgery. Pediatr Cardiol 2020; 41:1704-1713. [PMID: 32734528 PMCID: PMC7391225 DOI: 10.1007/s00246-020-02431-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/22/2020] [Indexed: 11/24/2022]
Abstract
Infants undergoing congenital heart surgery (CHS) with cardiopulmonary bypass (CPB) are at risk of acute kidney injury (AKI) and fluid overload. We hypothesized that placement of a passive peritoneal drain (PPD) can improve postoperative fluid output in such infants. We analyzed 115 consecutive patients, age birth to 60 days, admitted to the PICU after CHS with CPB between 2012 and 2018. Patients who needed postoperative ECMO were excluded. Linear and logistic regression models compared postoperative fluid balances, diuretics administration, AKI, vasoactive-inotropic scores (VIS), time intubated, and length of stay after adjusting for pre/operative predictors including STAT category, bypass time, age, weight, and open chest status. PPD patients had higher STAT category (p = 0.001), longer CPB times (p = 0.001), and higher VIS on POD 1-3 (p ≤ 0.005 daily). PPD patients also had higher AKI rates (p = 0.01) that did not reach significance in multivariable modeling. There were no postoperative deaths. Postoperative hours of intubation, hospital length of stay, and POD 1-5 fluid intake did not differ between groups. Over POD 1-5, PPD use accounted for 48.8 mL/kg increased fluid output (95% CI [2.2, 95.4], p = 0.043) and 3.41 mg/kg less furosemide administered (95% CI [1.69, 5.14], p < 0.001). No PPD complications were observed. Although PPD placement did not affect end-outcomes, it was used in higher acuity patients. PPD placement is associated with improved fluid output despite lower diuretic administration and may be a useful postoperative fluid management adjunct in some complex CHS patients.
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Affiliation(s)
- Kevin A. Pettit
- Department of Pediatrics, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Nicholas A. Schreiter
- School of Medicine and Public Health, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Entela B. Lushaj
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Joshua L. Hermsen
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Michael Wilhelm
- Department of Pediatrics, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Allison C. Redpath Mahon
- Department of Pediatrics, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Kari L. Nelson
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Joshua J. DeGrave
- School of Pharmacy, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Nicholas Marka
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Petros V. Anagnostopoulos
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA ,University of Wisconsin Department of Surgery Clinical Science Center, 600 Highland Ave, Madison, WI 53792 USA
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Rosen K, Wiesen MH, Oberthür A, Michels G, Roth B, Fietz C, Müller C. Drug-drug interactions in Neonatal Intensive Care Units: how to overcome a challenge. Minerva Pediatr (Torino) 2019; 73:188-197. [PMID: 31621271 DOI: 10.23736/s2724-5276.19.05388-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Critically ill patients in neonatal intensive-care units (NICU) are exposed to a large number of drugs. Clinical trials for safety, dosing and efficacy are lacking although age-dependent alterations of pharmacokinetics (PK), drug-drug-interactions (DDIs), as well as intravenous admixture incompatibilities (IAI) may impact drug efficacy and trigger side-effects in this vulnerable population. Consequently, implementation of a routinely used DDIs checking regimen may help guide in decision making and will assist clinicians to avoid serious and preventable events. Therefore, the goal of the present work is to identify and assess the risk of relevant DDIs of drugs commonly used in the NICU. EVIDENCE ACQUISITION A literature review study was performed to identify and further assess the risk of relevant DDIs of 48 drugs frequently used in the tertiary care NICU of the University Hospital of Cologne. DDIs were categorized into five different classes according to their severity (contraindicated, minor, moderate, and major DDI, IAI), based on the classification used in the Micromedex database. In the database a major interaction is defined as any interaction that can be life threatening and/or demands medical intervention to avoid severe adverse effects. Moderate interactions can lead to a degradation of the patient's status and demand an adjustment in the therapy, and minor interactions only have a limited clinical effect. All identified DDIs in the present study are presented as a Visual Interaction Triangle (VIT) and recommendations on the management of clinically significant DDIs are provided. EVIDENCE SYNTHESIS According to the classification used in the Micromedex database: a total of 160 (13.2%) possible interactions (DDI, IAI) were found. Fifty-five (4.9%) cases were categorized as serious interactions (DDI-major), 48 (4.2%) were less severe (DDI-moderate/minor) and in 52 (4.6%) cases an intravenous admixture drug interaction was found. Five (0.4%) drug-combinations were contraindicated. CONCLUSIONS In this web-based study, a total of 160 DDIs were identified. Although only 4.9% were classified as clinically relevant, practitioners can use the presented VIT as a unique clinical reference to avoid possible predictable adverse effects and to uncover possible drug-interaction potential.
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Affiliation(s)
- Kai Rosen
- Division of Therapeutic Drug Monitoring, Center of Pharmacology, University Hospital of Cologne, Cologne, Germany
| | - Martin H Wiesen
- Division of Therapeutic Drug Monitoring, Center of Pharmacology, University Hospital of Cologne, Cologne, Germany
| | - André Oberthür
- Unit of Neonatal and Pediatric Intensive Care Medicine, Children's Hospital, University Hospital of Cologne, Cologne, Germany
| | - Guido Michels
- Heart Center, Third Department of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Bernd Roth
- Unit of Neonatal and Pediatric Intensive Care Medicine, Children's Hospital, University Hospital of Cologne, Cologne, Germany
| | - Cornelia Fietz
- Division of Therapeutic Drug Monitoring, Center of Pharmacology, University Hospital of Cologne, Cologne, Germany
| | - Carsten Müller
- Division of Therapeutic Drug Monitoring, Center of Pharmacology, University Hospital of Cologne, Cologne, Germany -
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Abstract
OBJECTIVE To reduce bilateral delayed-onset progressive sensory permanent hearing loss using a systems-wide quality improvement project with adherence to best practice for the administration of furosemide. DESIGN Prospective cohort study with regular audiologic follow-up assessment of survivors both before and after a 2007-2008 quality improvement practice change. SETTING The referral center in Western Canada for complex cardiac surgery, with comprehensive multidisciplinary follow-up by the Complex Pediatric Therapies Follow-up Program. PATIENTS All consecutive patients having single-ventricle palliative cardiac surgery at age 6 weeks old or younger. INTERVENTIONS A 2007-2008 quality improvement practice change consisted of a Parenteral Drug Monograph revision indicating slow IV administration of furosemide, an educational program, and an evaluation. MEASUREMENTS AND MAIN RESULTS The outcome measure was the prevalence of permanent hearing loss by 4 years old. Firth multiple logistic regression compared pre (1996-2008) to post (2008-2012) practice change occurrence of permanent hearing loss, adjusting for confounding variables, including all hospital days, extracorporeal membrane oxygenation, cardiopulmonary bypass time, age at first surgery, dialysis, and sepsis. From 1996 to 2012, 259 infants had single-ventricle palliative surgery at age 6 weeks old or younger, with 173 (64%) surviving to age 4 years. Of survivors, 106 (61%) were male, age at surgery was 11.6 days (9.0 d), and total hospitalization days by age 4 years were 64 (42); 18 (10%) had cardiopulmonary resuscitation and 38 (22%) had sepsis at any time. All 173 (100%) had 4-year follow-up. Pre- to postpractice change permanent hearing loss dropped from 17/100 (17%) to 0/73 (0%) of survivors. On Firth multiple logistic regression, the only variable statistically associated with permanent hearing loss was the pre- to postpractice change time period (odds ratio, 0.03; 95% CI, 0-0.35; p = 0.001). CONCLUSIONS A practice change to ensure slow IV administration of furosemide eliminated permanent hearing loss. Centers caring for critically ill infants, particularly those with single-ventricle anatomy or hypoxia, should review their drug administration guidelines and adhere to best practice for administration of IV furosemide.
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Non-pharmacological management of a hemodynamically significant patent ductus arteriosus. Semin Fetal Neonatal Med 2018; 23:245-249. [PMID: 29580939 DOI: 10.1016/j.siny.2018.03.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The association between the patent ductus arteriosus (PDA) and neonatal morbidity, mortality and poor neurodevelopmental outcome in later childhood has been the focus of intense debate for decades. The lack of evidence supporting therapeutic strategies aimed at achieving PDA closure has led to the widespread adoption of conservative management aimed at mitigating the impact of shunt volume without achieving ductal closure. In this article, we review this management approach, describe the supportive evidence and potential complications associated with this strategy.
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Thompson EJ, Greenberg RG, Kumar K, Laughon M, Smith PB, Clark RH, Crowell A, Shaw L, Harrison L, Scales G, Bell N, Hornik CP. Association between Furosemide Exposure and Patent Ductus Arteriosus in Hospitalized Infants of Very Low Birth Weight. J Pediatr 2018; 199:231-236. [PMID: 29752171 PMCID: PMC6063759 DOI: 10.1016/j.jpeds.2018.03.067] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/26/2018] [Accepted: 03/27/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To evaluate the association between furosemide exposure and patent ductus arteriosus (PDA) in a large, contemporary cohort of hospitalized infants with very low birth weight (VLBW). STUDY DESIGN Using the Pediatrix Medical Group Clinical Data Warehouse, we identified all inborn infants of VLBW <37 weeks of gestation discharged from the neonatal intensive care unit after the first postnatal week from 2011 to 2015. We defined PDA as any medical (ibuprofen or indomethacin) or surgical PDA therapy. We collected data up to the day of PDA treatment or postnatal day 18 for infants not diagnosed with PDA. We performed multivariable logistic regression to evaluate the association between PDA and exposure to furosemide. RESULTS We included 43 576 infants from 337 neonatal intensive care units, of whom 6675 (15%) underwent PDA treatment. Infants with PDA were more premature and more often exposed to mechanical ventilation and inotropes. Furosemide was prescribed to 4055 (9%) infants. On multivariable regression, exposure to furosemide was associated with decreased odds of PDA treatment (OR 0.72; 95% CI 0.65-0.79). Increasing percentage of days with furosemide exposure was not associated with PDA treatment (OR 1.01; 95% CI 0.97-1.06). CONCLUSIONS Furosemide exposure was not associated with increased odds of PDA treatment in hospitalized infants of VLBW. Further studies are needed to characterize the efficacy and safety of furosemide in premature infants.
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Affiliation(s)
| | - Rachel G Greenberg
- Duke Clinical Research Institute & Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Karan Kumar
- Duke Clinical Research Institute & Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Matthew Laughon
- Department of Pediatrics & Division of Neonatology, University of North Carolina, Chapel Hill, NC
| | - P Brian Smith
- Duke Clinical Research Institute & Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Reese H Clark
- The Pediatrix-Obstetrix Center for Research, Education, and Quality, Sunrise, FL
| | | | - Layla Shaw
- Duke Star Program, Duke Clinical Research Institute, Durham, NC
| | - Louis Harrison
- Duke Star Program, Duke Clinical Research Institute, Durham, NC
| | | | - Nicole Bell
- Duke Star Program, Duke Clinical Research Institute, Durham, NC
| | - Christoph P Hornik
- Duke Clinical Research Institute & Department of Pediatrics, Duke University School of Medicine, Durham, NC.
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Pharande P, Watson H, Tan K, Sehgal A. Oral Paracetamol for Patent Ductus Arteriosus Rescue Closure. Pediatr Cardiol 2018; 39:183-190. [PMID: 29043398 DOI: 10.1007/s00246-017-1745-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/30/2017] [Indexed: 11/24/2022]
Abstract
The objective of this study was to ascertain the efficacy of oral paracetamol in closing a symptomatic patent ductus arteriosus (PDA) when used as 'rescue' option. After obtaining ethics approval, a retrospective appraisal of the data from April 2014 to July 2015 was performed. Infants who were administered oral paracetamol either after unsuccessful therapy with ibuprofen or where it was considered contraindicated were included. A previously published echocardiographic scoring schema to stratify for ductal disease severity was used. Using univariate analysis, characteristics of infants with successful closure were compared with partial (a priori reduction in composite score by ≥ 50% of pretreatment) or no closure. Twenty infants with gestation age and birthweight of 25.7 ± 1.5 weeks and 724.1 ± 143 g, respectively, were studied. Complete closure was noted in 10 (50%) infants with additional four infants showing a significant reduction in haemodynamic shunting. Gestational age at birth and at therapy, chronological age at therapy, birthweight and total fluid intake were comparable between the two groups. The pre-therapy composite score had a significant association with successful closure (the higher the echocardiographic score, the lesser the closure). Concomitant furosemide therapy and late-onset sepsis had a high likelihood ratio of unsuccessful closure (11.01 [2-tailed, p = 0.005] and 5.3 [2-tailed, p = 0.07]), respectively. Oral paracetamol may be a possible therapeutic option in premature infants where therapy with first-line agents is unsuccessful or contraindicated. Concomitant sepsis and furosemide administration may affect successful therapy.
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Affiliation(s)
- Pramod Pharande
- Monash Newborn, Monash Children's Hospital, 246 Clayton Road, Clayton, VIC, 3168, Australia.
| | - Hadley Watson
- Monash Newborn, Monash Children's Hospital, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Kenneth Tan
- Monash Newborn, Monash Children's Hospital, 246 Clayton Road, Clayton, VIC, 3168, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia
| | - Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, 246 Clayton Road, Clayton, VIC, 3168, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia
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Repercusión hemodinámica en pacientes neonatos con conducto arterioso persistente: factores asociados. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 87:248-251. [DOI: 10.1016/j.acmx.2016.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/16/2016] [Accepted: 05/18/2016] [Indexed: 11/21/2022] Open
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Girardi A, Galletti S, Raschi E, Koci A, Poluzzi E, Faldella G, De Ponti F. Pattern of drug use among preterm neonates: results from an Italian neonatal intensive care unit. Ital J Pediatr 2017; 43:37. [PMID: 28412957 PMCID: PMC5392975 DOI: 10.1186/s13052-017-0354-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/30/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Drug use in preterm neonates admitted to Neonatal Intensive Care Unit (NICU) has been investigated, so far, in terms of unauthorized or off-label use; very little is known on the use of combinations of different active substances, which is frequently required in this population (prophylaxis of infections, treatment of concomitant diseases). The aim of this study was to describe the most common patterns of drug use in an Italian NICU, focusing on those with nephrotoxic potential. METHODS Medical records of preterm neonates (<37 weeks of gestational age) weighing less than 1,500 g at birth and admitted to an Italian NICU were scrutinized in a 3-year retrospective investigation. Analysis included drug exposure, duration of therapies, co-administration of drugs with potential renal side effects; also daily protein supplement was calculated from parenteral nutrition. RESULTS A cohort of 159 preterm neonates was selected; 68 were born weighing less than 1,000 g (extremely low birth weight infants, ELBW, Group A), 91 weighed between 1,000 and 1,500 g at birth (Group B). Compared to Group B, neonates of Group A were more likely to receive pharmacological treatments: the most used drugs were antibiotics (especially ampicillin and amikacin, p = .07 and p < .001, respectively), antifungals (especially fluconazole, p < .001), and diuretics (especially furosemide, p < .001). Analysis of co-administration of drugs with potential nephrotoxicity showed ampicillin and amikacin as the most reported combination (94.1% of Group A and 31.9% of Group B), the combination of furosemide with antibacterials (ampicillin or amikacin) was also frequently reported, with average period of combination shorter than 2 days. CONCLUSIONS ELBW infants were exposed to a higher number of drugs compared to other neonates and were more likely to receive associations of drugs with nephrotoxic potential (e.g. furosemide and amikacin), though only for short cycles. Further studies should evaluate the safety profile (especially potential renal side effects) related to most commonly used combinations.
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Affiliation(s)
- A Girardi
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - S Galletti
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - E Raschi
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - A Koci
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - E Poluzzi
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - G Faldella
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - F De Ponti
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy. .,Present Address: Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48 40126, Bologna, Italy.
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Nicolas JM, Bouzom F, Hugues C, Ungell AL. Oral drug absorption in pediatrics: the intestinal wall, its developmental changes and current tools for predictions. Biopharm Drug Dispos 2017; 38:209-230. [PMID: 27976409 PMCID: PMC5516238 DOI: 10.1002/bdd.2052] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 11/21/2016] [Accepted: 11/30/2016] [Indexed: 12/14/2022]
Abstract
The dissolution, intestinal absorption and presystemic metabolism of a drug depend on its physicochemical characteristics but also on numerous physiological (e.g. gastrointestinal pH, volume, transit time, morphology) and biochemical factors (e.g. luminal enzymes and flora, intestinal wall enzymes and transporters). Over the past decade, evidence has accumulated indicating that these factors may differ in children and adults resulting in age-related changes in drug exposure and drug response. Thus, drug dosage may require adjustment for the pediatric population to ensure the desired therapeutic outcome and to avoid side-effects. Although tremendous progress has been made in understanding the effects of age on intestinal physiology and function, significant knowledge gaps remain. Studying and predicting pharmacokinetics in pediatric patients remains challenging due to ethical concerns associated with clinical trials in this vulnerable population, and because of the paucity of predictive in vitro and in vivo animal assays. This review details the current knowledge related to developmental changes determining intestinal drug absorption and pre-systemic metabolism. Supporting experimental approaches as well as physiologically based pharmacokinetic modeling are also discussed together with their limitations and challenges. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jean-Marie Nicolas
- Non-Clinical Development Department, UCB Biopharma sprl, Braine-l'Alleud, Belgium
| | - François Bouzom
- Non-Clinical Development Department, UCB Biopharma sprl, Braine-l'Alleud, Belgium
| | - Chanteux Hugues
- Non-Clinical Development Department, UCB Biopharma sprl, Braine-l'Alleud, Belgium
| | - Anna-Lena Ungell
- Non-Clinical Development Department, UCB Biopharma sprl, Braine-l'Alleud, Belgium
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Abstract
BACKGROUND The incidence of hemodynamically significant patent ductus arteriosus (hsPDA) increases with decreasing gestational age and is associated with many common morbidities of extreme prematurity. Controversies remain surrounding the definition of hsPDA, the population of infants requiring treatment, the appropriate timing and method of treatment, and the outcomes associated with PDA and its therapies. PURPOSE This integrative literature review focuses on diagnostic and treatment recommendations derived from the highest levels of evidence. SEARCH STRATEGY PubMed and CINAHL were searched using key words "neonatal" and "patent ductus arteriosus" to discover the highest levels of evidence surrounding diagnosis, treatment methods, and outcomes. FINDINGS/RESULTS The lack of consensus surrounding the diagnosis and clinical significance of PDA hinders meta-analysis across studies and confounds understanding of appropriate management strategies. Novel biomarkers, pharmaceutical choices, and transcatheter closure methods are expanding diagnostic and treatment options. IMPLICATIONS FOR PRACTICE Infants weighing less than 1000 g are at highest risk. Prophylactic closure is no longer recommended, although early asymptomatic therapy is still preferred by some to avoid prolonged pulmonary overcirculation or decreased renal and gut perfusion. Conservative treatment measures such as fluid restriction and diuretic administration have not consistently proven effective and are in some instances detrimental. Cyclooxygenase inhibitors are effective but have adverse renal and mesenteric effects. Oral ibuprofen is associated with lower instance of necrotizing enterocolitis. IMPLICATIONS FOR RESEARCH Well-defined staging criteria would aid in comparison and meta-analysis. Trials that include a control group that receives no therapy may help separate the outcomes associated with prematurity from those associated with PDA.
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A Mechanism to Explain Ototoxicity in Neonates Exposed to Bumetamide: Lessons to Help Improve Future Product Development in Neonates. Paediatr Drugs 2016; 18:331-3. [PMID: 27538744 DOI: 10.1007/s40272-016-0190-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Médicaments ototoxiques et oculotoxiques : la vigilance du pharmacien. ACTUALITES PHARMACEUTIQUES 2016. [DOI: 10.1016/j.actpha.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Only a small fraction of drugs widely used in neonatal intensive care units (NICU) are specifically authorized for this population. Even if unlicensed or off-label use is necessary, it is associated with increased adverse drug reactions, which must be carefully weighed against expected benefits. In particular, renal damage is frequent among preterm babies, and is considered a predisposing factor for the development of chronic kidney disease in adulthood. Apart from specific conditions affecting premature neonates (e.g. respiratory distress syndrome, perinatal asphyxia), drugs play an important role in impairing renal function because of well-known nephrotoxicity and/or interaction with renal developmental factors. From a review of the available studies on drug use in NICU patients, we identified and described the most commonly administered drugs that are correlated to renal damage. Early detection of kidney injury is becoming an essential aspects for clinicians because of the limited number of biomarkers applicable in the neonatal population. Postnatal changes of biochemical processes that influence pharmacokinetic and pharmacodynamic aspects need to be further investigated in order to better understand the mechanisms of drug toxicity in this population. The most promising strategies for dose adjustment and therapeutic schemes are discussed. The purpose of this review was to describe current knowledge on drug use among premature babies and their implication in kidney injury development, as well as to highlight available strategies for early detection of renal damage.
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Barbosa SF, Takatsuka T, Tavares GD, Araújo GLB, Wang H, Vehring R, Löbenberg R, Bou-Chacra NA. Physical-chemical properties of furosemide nanocrystals developed using rotation revolution mixer. Pharm Dev Technol 2015; 21:812-822. [PMID: 27825283 DOI: 10.3109/10837450.2015.1063650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Recently, several approaches have been reported to improve the dissolution rate and bioavailability of furosemide, a class IV drug. However, to the best of our knowledge, none of them proposed nanocrystals. In the last decade, nanocrystals successfully addressed solubility issues by increasing surface area and saturation solubility, both leading to an increase in the dissolution rate of poor water soluble drugs. The preparation of furosemide nanocrystals was by a rotation revolution mixer method. Size distribution and morphology were performed using laser diffraction and scanning electron microscopy, respectively. In addition, differential scanning calorimetry, thermogravimetry, X-ray powder diffraction (XRD) and low frequency shift-Raman spectroscopy allowed investigating the thermal properties and crystalline state. Solubility saturation and intrinsic dissolution rate (IDR) studies were conducted. The thermal analysis revealed lower melting range for the nanocrystals comparing to furosemide. Moreover, a slight crystalline structure change to the amorphous state was observed by XRD and confirmed by low frequency shift Raman. The particle size was reduced to 231 nm with a polydispersity index of 0.232, a 30-fold reduction from the original powder. Finally, the saturation solubility and IDR showed a significant increase. Furosemide nanocrystals showed potential for development of innovative formulations as an alternative to the commercial products.
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Affiliation(s)
- Sávio Fujita Barbosa
- a Faculty of Pharmaceutical Sciences , University of São Paulo , São Paulo , São Paulo , Brazil
| | | | - Guilherme Diniz Tavares
- c Course of Pharmacy, Department of Biochemistry , Institute of Biology, State University of Campinas , Campinas , São Paulo , Brazil , and
| | | | - Hui Wang
- d Faculty of Pharmacy and Pharmaceutical Sciences , Katz Group-Rexall Centre for Pharmacy & Health Research, University of Alberta , Edmonton , Alberta , Canada
| | - Reinhard Vehring
- d Faculty of Pharmacy and Pharmaceutical Sciences , Katz Group-Rexall Centre for Pharmacy & Health Research, University of Alberta , Edmonton , Alberta , Canada
| | - Raimar Löbenberg
- d Faculty of Pharmacy and Pharmaceutical Sciences , Katz Group-Rexall Centre for Pharmacy & Health Research, University of Alberta , Edmonton , Alberta , Canada
| | - Nádia Araci Bou-Chacra
- a Faculty of Pharmaceutical Sciences , University of São Paulo , São Paulo , São Paulo , Brazil
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