viernes, 17 de abril de 2015

Síndrome de abstinencia neonatal/Neonatal abstinence syndrome

El síndrome de abstinencia neonatal: Esencial para el médico.
Neonatal abstinence syndrome: essentials for the practitioner.
Siu A, Robinson CA.
J Pediatr Pharmacol Ther. 2014 Jul;19(3):147-55. doi: 10.5863/1551-6776-19.3.147.
The incidence of neonatal abstinence syndrome (NAS) has increased dramatically during the past 15 years, likely due to an increase in antepartum maternal opiate use. Optimal care of these patients is still controversial because of the available published literature lacking sufficient sample size, placebo control, and comparative pharmacologic trials. Primary treatment for NAS consists of opioid replacement therapy with either morphine or methadone. Paregoric and tincture of opium have been abandoned because of relative safety concerns. Buprenorphine is emerging as a treatment option with promising initial experience. Adjunctive agents should be considered for infants failing treatment with opioid monotherapy. Traditionally, phenobarbital has been used as adjunctive therapy; however, results of clonidine as adjunctive therapy for NAS appear to be beneficial. Future directions for research in NAS should include validating a simplified scoring tool, conducting comparative studies, exploring home management options, and optimizing management through pharmacogenomics.
KEYWORDS: abstinence syndrome; buprenorphine; clonidine; methadone; morphine
La abstinencia neonatal de opiáceos y la prescripción de opioides prenatal.
Neonatal opioid withdrawal and antenatal opioid prescribing.
Turner SD, Gomes T, Camacho X, Yao Z, Guttmann A, Mamdani MM, Juurlink DN, Dhalla IA.
CMAJ Open. 2015 Jan 13;3(1):E55-61. doi: 10.9778/cmajo.20140065.
BACKGROUND: The incidence of neonatal opioid withdrawal is increasing in both Canada and the United States. However, the degree to which the treatment of pain with opioids, rather than the misuse of prescription opioids or heroin, contributes to the prevalence of neonatal opioid withdrawal remains unknown. METHODS: We conducted a retrospective, population-based, cross-sectional study between 1992 and 2011 in Ontario with 2 objectives. First, we determined the annual incidence of neonatal abstinence syndrome. Second, using data from a subset of women eligible for publicly funded prescription drugs, we determined what proportion of women who deliver an infant with neonatal abstinence syndrome were given a prescription for an opioid before and during pregnancy. RESULTS: The incidence of neonatal abstinence syndrome in Ontario increased 15-fold during the study period, from 0.28 per 1000 live births in 1992 to 4.29 per 1000 live births in 2011. During the final 5 years of the study, we identified 927 deliveries of infants with neonatal abstinence syndrome to mothers who were public drug plan beneficiaries. Of these mothers, 67% had received an opioid prescription in the 100 days preceding delivery, including 53.3% who received methadone, an increase from 28.6% in the interval spanning 1 to 2 years before delivery (p < 0.001). Prescription for nonmethadone opioids decreased from 38% to 17% (p < 0.001). INTERPRETATION: The incidence of neonatal opioid withdrawal in Ontario has increased substantially over the last 20 years. Most of the women in this cohort who delivered an infant with neonatal abstinence syndrome had received a prescription for an opioid both before and during their pregnancy.
Reducción de narcóticos en el embarazo con morfina de acción prolongada: un estudio de cohorte prospectivo de 18 meses en el noroeste de Ontario.
Narcotic tapering in pregnancy using long-acting morphine: an 18-month prospective cohort study in northwestern Ontario.
Dooley R, Dooley J, Antone I, Guilfoyle J, Gerber-Finn L, Kakekagumick K, Cromarty H, Hopman W, Muileboom J, Brunton N, Kelly L.
Can Fam Physician. 2015 Feb;61(2):e88-95.
OBJECTIVE:  To document the management of and outcomes for patients receiving narcotic replacement and tapering with long-acting morphine preparations during pregnancy. DESIGN: A prospective cohort study over 18 months. SETTING: Northwestern Ontario. PARTICIPANTS: All 600 births at Meno Ya Win Health Centre in Sioux Lookout, Ont, from January 1, 2012, to June 30, 2013, including 166 narcotic-exposed pregnancies. INTERVENTION: Narcotic replacement and tapering of narcotic use with long-acting morphine preparations. MAIN OUTCOME MEASURES: Prenatal management of maternal narcotic use, incidence of neonatal abstinence syndrome, and other neonatal outcomes. RESULTS: The incidence of neonatal abstinence syndrome fell significantly to 18.1% of pregnancies exposed to narcotics (from 29.5% in a previous 2010 study, P = .003) among patients using narcotic replacement and tapering with long-acting morphine preparations. Neonatal outcomes were otherwise equivalent to those of the nonexposed pregnancies. CONCLUSION: In many patients, long-acting morphine preparations can be safely used and tapered in pregnancy, with a subsequent decrease in observed neonatal withdrawal symptoms.
Helen Gharaee
Anestesia y Medicina del Dolor
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