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• W2912538098 abstract "Authors' replySir—With regard to Peter Raupp's questions on efficacy, experimental evidence suggests that acetazolamide and furosemide are synergistic in reducing production of CSF. The only study to suggest a benefit of diuretic therapy (albeit uncontrolled) used the two drugs in combination.1Shinnar S Gammon K Bergman EW Epstein M Freeman JM Management of hydrocephalus in infancy: use of acetazolamide and furosemide to avoid cerebrospinal fluid shunts.J Pediatr. 1985; 107: 31-37Summary Full Text PDF PubMed Scopus (73) Google Scholar Adverse effects of furosemide are not likely to compromise the efficacy of diuretic therapy. Nephrocalcinosis, which may also follow acetazolamide monotherapy, was the only such adverse effect noted in our trial and led to termination of drug therapy in two (3%) infants. There is no published evidence (other than from our trial) that furosemide is “unnecessary” in the treatment of hydrocephalus. Raupp cites one uncontrolled study,2Mercuri E Faundez JC Cowan F Dubowitz L Acetazolamide without frusemide in the treatment of posthaemorrhagic hydrocephalus.Acta Paediatr. 1994; 83: 1319-1321Crossref PubMed Scopus (5) Google Scholar in which two infants did not tolerate acetazolamide but their progress is not further described; in the other three, Mercuri and colleagues postulated that had the infants not received the drug, their ventricular size might have increased at a faster rate.We recommended continuation of drug. therapy for 6 months, but accepted cautious weaning from drug therapy in infants whose ventricular size had decreased or not changed over more than 4 weeks on drug therapy. Only five (7%) infants required a second course of drug therapy. Had insufficient duration of drug therapy added to the number who required shunt placement, this effect would have been apparent as an increase in the time between trial entry and shunt placement, compared with infants given standard therapy, but this was not the case (mean interval 58·1 vs 61·5 days).Furosemide can cause osteopaenia and nephrocalcinosis in infants although adverse long-term effects are not reported.3Jones CA King S Shaw NJ Judd BA Renal calcification in preterm infants: follow up at 4–5 years.Arch Dis Child. 1997; 76: 185-189Crossref Scopus (35) Google Scholar Acetazolamide is also a cause of nephrocalcinosis and renal stones. Far from ignoring the literature, we required participating centres to obtain a renal ultrasound scan after 12 weeks of drug therapy. Raupp implies that carbon dioxide retention would be reduced by the use of polycitra, instead of sodium bicarbonate and potassium chloride, but cites no evidence. This adverse effect results from the production of carbon dioxide when bicarbonate ions are added to correct an excess of hydrogen ions and are likely to pose similar problems with both alkalising agents. Sodium retention is rarely a problem in this population of infants who frequently require sodium supplements to correct leak of sodium from the kidneys.Previous trials have not shown that CSF taps were ineffective, but rather that early taps (before excessive head growth) were no more effective than late taps.4Ventriculomegaly Trial GroupRandomised trial of early tapping in neonatal posthaemorrhagic ventricular dilatation: results at 30 months.Arch Dis Child. 1994; 70: F129-F136Crossref PubMed Scopus (11) Google Scholar We, therefore, recommended that CSF taps were delayed until head growth was greater than 1·5 cm per week for at least 2 weeks. We also provided treatment guidelines for shunt placement. Our use of CSF taps was not a confounding factor since there were no significant differences in CSF taps between treatment groups.Correspondence between intention to treat and treatment given was good in the trial with acetazolamide given to 96% of infants assigned drug therapy plus standard therapy, compared with 4% of infants assigned standard therapy alone. The use of furosemide for cardiac or respiratory indications in a further 14% of infants in the standard therapy group was inevitable in a pragmatic study, but is presumably of no relevance to Raupp's argument if he believes that furosemide is of no benefit in hydrocephalus.We found maximum tolerable doses of acetazolamide and furosemide were ineffective in delaying or preventing shunt placement for neonatal posthaemorrhagic ventricular dilatation. That either of the two drugs alone is effective is improbable. The question of keeping adverse effects to a minimum by reducing the diuretic therapy does not arise. Authors' reply Sir—With regard to Peter Raupp's questions on efficacy, experimental evidence suggests that acetazolamide and furosemide are synergistic in reducing production of CSF. The only study to suggest a benefit of diuretic therapy (albeit uncontrolled) used the two drugs in combination.1Shinnar S Gammon K Bergman EW Epstein M Freeman JM Management of hydrocephalus in infancy: use of acetazolamide and furosemide to avoid cerebrospinal fluid shunts.J Pediatr. 1985; 107: 31-37Summary Full Text PDF PubMed Scopus (73) Google Scholar Adverse effects of furosemide are not likely to compromise the efficacy of diuretic therapy. Nephrocalcinosis, which may also follow acetazolamide monotherapy, was the only such adverse effect noted in our trial and led to termination of drug therapy in two (3%) infants. There is no published evidence (other than from our trial) that furosemide is “unnecessary” in the treatment of hydrocephalus. Raupp cites one uncontrolled study,2Mercuri E Faundez JC Cowan F Dubowitz L Acetazolamide without frusemide in the treatment of posthaemorrhagic hydrocephalus.Acta Paediatr. 1994; 83: 1319-1321Crossref PubMed Scopus (5) Google Scholar in which two infants did not tolerate acetazolamide but their progress is not further described; in the other three, Mercuri and colleagues postulated that had the infants not received the drug, their ventricular size might have increased at a faster rate. We recommended continuation of drug. therapy for 6 months, but accepted cautious weaning from drug therapy in infants whose ventricular size had decreased or not changed over more than 4 weeks on drug therapy. Only five (7%) infants required a second course of drug therapy. Had insufficient duration of drug therapy added to the number who required shunt placement, this effect would have been apparent as an increase in the time between trial entry and shunt placement, compared with infants given standard therapy, but this was not the case (mean interval 58·1 vs 61·5 days). Furosemide can cause osteopaenia and nephrocalcinosis in infants although adverse long-term effects are not reported.3Jones CA King S Shaw NJ Judd BA Renal calcification in preterm infants: follow up at 4–5 years.Arch Dis Child. 1997; 76: 185-189Crossref Scopus (35) Google Scholar Acetazolamide is also a cause of nephrocalcinosis and renal stones. Far from ignoring the literature, we required participating centres to obtain a renal ultrasound scan after 12 weeks of drug therapy. Raupp implies that carbon dioxide retention would be reduced by the use of polycitra, instead of sodium bicarbonate and potassium chloride, but cites no evidence. This adverse effect results from the production of carbon dioxide when bicarbonate ions are added to correct an excess of hydrogen ions and are likely to pose similar problems with both alkalising agents. Sodium retention is rarely a problem in this population of infants who frequently require sodium supplements to correct leak of sodium from the kidneys. Previous trials have not shown that CSF taps were ineffective, but rather that early taps (before excessive head growth) were no more effective than late taps.4Ventriculomegaly Trial GroupRandomised trial of early tapping in neonatal posthaemorrhagic ventricular dilatation: results at 30 months.Arch Dis Child. 1994; 70: F129-F136Crossref PubMed Scopus (11) Google Scholar We, therefore, recommended that CSF taps were delayed until head growth was greater than 1·5 cm per week for at least 2 weeks. We also provided treatment guidelines for shunt placement. Our use of CSF taps was not a confounding factor since there were no significant differences in CSF taps between treatment groups. Correspondence between intention to treat and treatment given was good in the trial with acetazolamide given to 96% of infants assigned drug therapy plus standard therapy, compared with 4% of infants assigned standard therapy alone. The use of furosemide for cardiac or respiratory indications in a further 14% of infants in the standard therapy group was inevitable in a pragmatic study, but is presumably of no relevance to Raupp's argument if he believes that furosemide is of no benefit in hydrocephalus. We found maximum tolerable doses of acetazolamide and furosemide were ineffective in delaying or preventing shunt placement for neonatal posthaemorrhagic ventricular dilatation. That either of the two drugs alone is effective is improbable. The question of keeping adverse effects to a minimum by reducing the diuretic therapy does not arise. Acetazolamide in posthaemorrhagic ventricular dilatationThe message of the randomised controlled trial of acetazolamide in posthaemorrhagic ventricular dilatation presented by the PHVD Drug Trial Group (Aug 8, p 433)1 is clear cut. Therapy with acetazolamide and furosemide is not only unhelpful, but probably even harmful in preterm babies with posthaemorrhagic hydrocephalus, and can no longer be recommended. However, their study design and the findings preclude a final conclusion on drug therapy in neonatal posthaemorrhagic hydrocephalus. Full-Text PDF" @default.
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• W2912538098 title "Acetazolamide in posthaemorrhagic ventricular dilatation" @default.
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