Buprenorphine optimal treatment for neonatal abstinence syndrome
In a recent meta-analysis published in JAMA Pediatrics, buprenorphine was the optimal treatment for neonatal abstinence syndrome, whereas morphine — considered the standard of care in most hospitals — was consistently among the least effective treatments.
Researchers examined the findings of 18 randomized clinical trials (n = 1,072) published through June 2018. Length of treatment was the primary outcome, whereas length of stay, the need for adjuvant therapy and adverse events were secondary outcomes. The treatments included buprenorphine, clonidine, diluted tincture of opium and clonidine, diluted tincture of opium, morphine, methadone and phenobarbital.
The researchers reported that sublingual buprenorphine was considered optimal choice for reducing the length of treatment (mean difference in days vs. morphine, –12.75; vs. clonidine, –2.19) and the length of stay (mean difference in days vs. morphine, –11.43; vs. clonidine, –5.35).
“The worst treatments in terms of relative effects and rankings were morphine and phenobarbital monotherapies,” the researchers wrote. “These findings are of particular interest within the existing observational literature, which finds that morphine and phenobarbital are the most frequently used pharmacological approaches in the United States and Canada. The [AAP] highlights that phenobarbital is most commonly used only as adjuvant therapy, raising additional concerns regarding the rationale used by centers that use phenobarbital monotherapy as a first-line treatment.”
Elisha M. Wachman, MD, attending neonatologist at Boston Medical Center and assistant professor of pediatrics at the Boston University School of Medicine, told Infectious Diseases in Children that “the findings are limited due to the small number of well-designed studies in the field, variable NAS treatment protocols and study inclusion criteria, and lack of head-to-head comparison of some medications.”
Wachman, who co-authored an editorial that was published alongside the meta-analysis, said “future multicentered randomized control trials that take into account hospital care setting and care practices, and that examine outcomes beyond the inpatient hospitalization are warranted.” – by Bruce Thiel
Disclosures: Wachman reports that she received grant support from the National Institute of Child Health and Human Development. Please see the study and editorial for all other authors’ relevant financial disclosures.