What is the action of medication on NELSA (Newborn Early Life Support Algorithm)?

From the Guidelines

The action of medication, specifically in the context of neonatal abstinence syndrome (NAS), should be thoroughly discussed with patients to ensure comprehensive understanding and proper management of the condition, as evidenced by the various pharmacologic treatments available, including opioids, sedatives, and adjunctive therapies like clonidine 1. When considering the management of NAS, it's crucial to understand the mechanism of action of the medications used, such as how opioids like morphine and methadone work to reduce withdrawal symptoms, or how clonidine, an α2-adrenergic receptor agonist, palliates symptoms of autonomic over-activity 1. Key points to discuss with patients regarding the action of medication for NAS include:

• The role of opioids in reducing withdrawal symptoms and their potential side effects 1
• The use of adjunctive therapies like clonidine to manage autonomic symptoms and its potential benefits in reducing the duration of treatment 1
• The importance of individualized treatment plans, as the effectiveness of different medications can vary depending on the specific circumstances of the patient, such as the type of opioid exposure and the severity of withdrawal symptoms 1 By thoroughly discussing the action of medication with patients, healthcare providers can ensure that patients have a comprehensive understanding of their treatment plan and can make informed decisions about their care. In the context of NAS, understanding the action of medication is critical for managing the condition effectively and minimizing potential complications, as highlighted by the American Academy of Pediatrics statement on the topic 1.

From the Research

NELSA and Action of Medication

• The action of medication, including NELSA, was discussed in various studies, focusing on the efficacy and tolerability of different antiepileptic drugs 2, 3, 4, 5, 6.
• These studies compared the effectiveness of various medications, such as levetiracetam, lamotrigine, valproate, and zonisamide, in treating different types of epilepsy, including focal and generalized epilepsy.

Efficacy of Antiepileptic Drugs

• A study published in 2021 found that levetiracetam did not meet the criteria for non-inferiority compared to lamotrigine in treating focal epilepsy, while zonisamide did meet the criteria 2.
• Another study published in 2017 found that levetiracetam performed significantly better than carbamazepine and lamotrigine in terms of time to withdrawal of allocated treatment for individuals with partial seizures 3.
• A network meta-analysis published in 2018 found that lamotrigine, levetiracetam, and topiramate were as effective as valproate in treating generalized tonic-clonic, tonic, and clonic seizures 4.

Tolerability of Antiepileptic Drugs

• A study published in 2017 found that patients taking carbamazepine, sodium valproate, lamotrigine, and levetiracetam reported similar efficacy and tolerability, with the most common adverse events being central nervous system effects such as drowsiness, headache, and dizziness 5.
• Another study published in 2022 found that levetiracetam was the most commonly used antiseizure medication, followed by gabapentin and valproate, and that gabapentin was the most common second- and third-line medication 6.

Treatment Pathways

• The 2022 study also found that there were 22,288 unique treatment pathways, with levetiracetam monotherapy being the most common pathway, followed by gabapentin monotherapy and valproate monotherapy 6.
• The study also found that neurologists were more likely to prescribe lamotrigine, levetiracetam, and lacosamide, while non-neurologists were more likely to prescribe gabapentin and valproate.