Phenobarbital, Midazolam Pharmacokinetics, Effectiveness, and Drug-Drug Interaction in Asphyxiated Neonates Undergoing Therapeutic Hypothermia

Laurent M.A. Favié, Floris Groenendaal, Marcel P.H. Van Den Broek, Carin M.A. Rademaker, Timo R. De Haan, Henrica L.M. Van Straaten, Peter H. Dijk, Arno Van Heijst, Sinno H.P. Simons, Koen P. Dijkman, Monique Rijken, Inge A. Zonnenberg, Filip Cools, Alexandra Zecic, Johanna H. Van Der Lee, Debbie H.G.M. Nuytemans, Frank Van Bel, Toine C.G. Egberts, Alwin D.R. Huitema

Research output: Contribution to journalArticleAcademicpeer-review


Background: Phenobarbital and midazolam are commonly used drugs in (near-)term neonates treated with therapeutic hypothermia for hypoxic-ischaemic encephalopathy, for sedation, and/or as anti-epileptic drug. Phenobarbital is an inducer of cytochrome P450 (CYP) 3A, while midazolam is a CYP3A substrate. Therefore, co-treatment with phenobarbital might impact midazolam clearance. Objectives: To assess pharmacokinetics and clinical anti-epileptic effectiveness of phenobarbital and midazolam in asphyxiated neonates and to develop dosing guidelines. Methods: Data were collected in the prospective multicentre PharmaCool study. In the present study, neonates treated with therapeutic hypothermia and receiving midazolam and/or phenobarbital were included. Plasma concentrations of phenobarbital and midazolam including its metabolites were determined in blood samples drawn on days 2-5 after birth. Pharmacokinetic analyses were performed using non-linear mixed effects modelling; clinical effectiveness was defined as no use of additional anti-epileptic drugs. Results: Data were available from 113 (phenobarbital) and 118 (midazolam) neonates; 68 were treated with both medications. Only clearance of 1-hydroxy midazolam was influenced by hypothermia. Phenobarbital co-administration increased midazolam clearance by a factor 2.3 (95% CI 1.9-2.9, p < 0.05). Anticonvulsant effectiveness was 65.5% for phenobarbital and 37.1% for add-on midazolam. Conclusions: Therapeutic hypothermia does not influence clearance of phenobarbital or midazolam in (near-)term neonates with hypoxic-ischaemic encephalopathy. A phenobarbital dose of 30 mg/kg is advised to reach therapeutic concentrations. Phenobarbital co-administration significantly increased midazolam clearance. Should phenobarbital be substituted by non-CYP3A inducers as first-line anticonvulsant, a 50% lower midazolam maintenance dose might be appropriate to avoid excessive exposure during the first days after birth.

Original languageEnglish
Pages (from-to)154-162
Number of pages9
Issue number2
Early online date28 Jun 2019
Publication statusPublished - 1 Aug 2019


  • Hypoxic-ischaemic encephalopathy
  • Midazolam
  • Neonates
  • Pharmacokinetics
  • Phenobarbital


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