T. Valaes et al., CONTROL OF HYPERBILIRUBINEMIA IN GLUCOSE-6-PHOSPHATE DEHYDROGENASE-DEFICIENT NEWBORNS USING AN INHIBITOR OF BILIRUBIN PRODUCTION, SN-MESOPORPHYRIN, Pediatrics, 101(5), 1998, pp. 11-17
Background. Hyperbilirubinemia in newborns with glucose-6-phosphate de
hydrogenase (G6PD) deficiency is a serious clinical problem because of
the severity and unpredictability of its course. An innovative approa
ch to this problem is suggested by previous experience with Sn-mesopor
phyrin (SnMP), a potent inhibitor of bilirubin production, in moderati
ng neonatal hyperbilirubinemia caused by ABO incompatibility, immaturi
ty, and unspecified mechanisms. Objective. To compare the effectivenes
s of the preventive and therapeutic uses of SnMP in ameliorating the c
ourse of bilirubinemia of G6PD-deficient neonates. Methods. Neonates b
orn at the Metera Maternity Hospital, Athens, Greece, and found to be
G6PD-deficient by cord blood testing were stratified by sex and gestat
ional age (210-265 days and >265 days) and randomized in pairs to rece
ive SnMP (6 mu mol/kg birth weight, intramuscularly) either on the fir
st day of life (preventive use) or if and when the plasma bilirubin co
ncentration (PBC) level reached an age-specific threshold level for in
tervention (therapeutic use). In the case of failure of SnMP to contro
l the rise of PBC levels, the protocol defined precisely the threshold
PBC levels for switchover to phototherapy (PT) and, if necessary, exc
hange transfusion. PBC was measured daily until a declining value was
obtained and the case was closed. Results. A total of 86 G6PD-deficien
t neonates were randomized: 42 in the preventive arm and 44 in the the
rapeutic arm. Of the latter, 20 (45%) reached PBC levels requiring the
rapeutic intervention and thus received SnMP. Regardless of the trial
arm, none of the 86 neonates required PT, whereas in a previous study
in the same population, 33% of G6PD-deficient neonates required PT. In
the intrapair sequential analysis, the favored arm was decided on the
criterion of the age at closure of the case being shorter by at least
1 day. After plotting 30 untied pairs in the sequential analysis grap
h, the preventive use of SnMP proved to be the favored arm, and the tr
ial was stopped. At this point, there were 2 unpaired neonates, 12 tie
d pairs, 22 pairs in which the preventive use of SnMP was favored and
8 pairs in which the therapeutic use of SnMP was favored. In the group
analysis, infants in the preventive group, compared with those in the
therapeutic group, had a lower maximum PBC level (8.2 +/- 3.1 and 10.
9 +/- 2.8 mg/dL, respectively), which was reached at an earlier age (6
3.5 +/- 34.8 and 82.2 +/- 24.7 hours, respectively) as well as a lower
closing PBC level (7.2 +/- 2.9 and 9.6 +/- 2.5 mg/dL, respectively) a
nd an earlier age at closing (89.1 +/- 35.6 and 110.8 +/- 23.6 hours,
respectively). Moreover, a PBC level of greater than or equal to 8.0 m
g/dL, a level at which jaundice is clearly visible, was not reached by
52% of the neonates in the preventive arm and 16% of the neonates in
the therapeutic arm. Conclusions. In G6PD-deficient neonates, a single
dose of SnMP administered preventively or therapeutically entirely su
pplanted the need for PT to control hyperbilirubinemia. The preventive
use of SnMP offers practical advantages in populations with a high en
ough prevalence of G6PD deficiency to justify cord blood screening.