CAPITOLO 4 IL DOSAGGIO DEI FARMACI IN ETA’ PEDIATRICA
4.2 Esempi di dosaggio dei farmaci più comunemente usati nella popolazione pediatrica
Le Penicilline sono tra gli antibiotici più comunemente prescritti per i bambini di tutto il mondo.[128] Negli ultimi anni, vista la crescita esponenziale delle prescrizioni di
antibiotici inappropriate, sia per i bambini che per gli adulti, si cerca di limitarne per evitare ulteriori fenomeni di resistenza antimicrobica.
Nel Regno Unito, la prescrizione pediatrica di solito segue le raccomandazioni di dosaggio del British National Formulary for Children (BNFC). Le linee guida, secondo BNFC, del dosaggio pediatrico per la penicillina orale sono rimaste sostanzialmente invariate per molti decenni; questo dovuto ad esempio dalla prevalenza dell'obesità infantile e della resistenza antimicrobica. Il BNFC raccomanda di somministrare penicilline orali nei bambini in base a fasce di età, a fasce di peso o ai calcoli basati sul peso corporeo e di raddoppiare la dose in caso di malattia grave. Le penicilline orali più comunemente prescritte per la popolazione pediatrica in Inghilterra sono: Amoxicillina, fenossimetilpenicillina (penicillina V) e flucloxacillina. Le prescrizioni sono 65.737 per penicilline orali scritte per 45.940 bambini: di cui amoxicillina (63%), penicillina V (17%) e flucloxacillina (20%).[129]
I dati ottenuti nel 2011-2012 dal BNFC sul dosaggio a seconda della fascia d’età del paziente per ciascuna penicillina erano le seguenti: ogni singola dose si dimezza tra le fasce d'età dai bambini di età compresa tra 12-18 anni (500 mg), a 6-12 anni (250 mg), a 1-5 anni (125 mg), per i bambini di età inferiore a 1 anno (62,5 mg).
FIG. 4 - DOSI AMOXICILLINA NELLE VARIE FASCE D’ETA’[130]
La figura 4 mostra la ripartizione dettagliata delle dosi unitarie di amoxicillina prescritta per ciascuna fascia d'età nel 2010 e include la percentuale di corrette dosi prescritte per ciascun gruppo di anni secondo la guida BNFC.
Nel dettaglio:
• nella fascia di età inferiore a 1 anno, a nessun bambino è stata prescritta la dose unitaria raccomandata (62,5 mg), ma la maggior parte ha ricevuto il doppio della dose (125 mg);
• nella fascia di età 1-5 anni, al 96% è stata prescritta la dose unitaria raccomandata (125 mg);
• il 40% dei bambini tra i 6 e i 12 anni e il 70% di quelli tra i 12 e i 18 anni hanno ricevuto dosi unitarie inferiori alle raccomandazioni date da BNFC.
Modelli simili di prescrizione per fascia d'età sono stati trovati anche per la penicillina V e la flucloxacillina:
• per bambini di età inferiore ad un anno, non è stata prescritta la dose unitaria raccomandata (62,5 mg) per penicillina V o flucloxacillina;
• la maggior parte dei bambini nella fascia di età 1-5 anni hanno ricevuto la dose unitaria raccomandata (125 mg) di penicillina V e flucloxacillina;
• tra i bambini di 6-12 anni, i bambini di età inferiore a 9 anni sono stati curati con penicillina V e flucloxacillina con la dose unitaria raccomandata per la fascia di età 1-5 anni (125 mg), mentre ai bambini di età compresa tra 9 e 12 anni è stato prescritto il dose unitaria raccomandata (250 mg);
• nella fascia di età 12-18 anni, a nessun bambino è stata prescritta penicillina V e meno della metà dei bambini a cui hanno prescritto flucloxacillina, ha ricevuto la dose unitaria raccomandata (500 mg).[130]
Nel caso delle prescrizioni di amoxicillina per l'otite media acuta e le relative infezioni dell'orecchio interno (l'indicazione di prescrizione più comune per l'amoxicillina) sono state analizzate separatamente. Per l'otite media e le relative infezioni dell'orecchio interno, i bambini (di età inferiore ad un anno) erano gli unici a ricevere la dose raccomandata di amoxicillina (40-90 mg/kg/die). Per i bambini di età compresa tra 4 e 15 anni, le prescrizioni equivalevano a 10-20 mg/kg/die, circa il 33% della dose raccomandata.[131]
Penicillina V
CAPITOLO 5 - CONCLUSIONE
Nonostante ci siano stati enormi progressi negli ultimi decenni nel campo della farmacoterapia pediatrica, ancora oggi ci sono molte domande senza risposta.
Sicuramente oggi è chiaro che i bambini non possono essere considerati come adulti in miniatura e la semplice estrapolazione dai dati degli adulti non può essere eseguita. Per questo bisogna concentrarsi sulle differenze farmacocinetiche e farmacodinamiche che si hanno tra la popolazione pediatrica e adulta.
Il profilo farmacocinetico di molti farmaci è stato ben definito ma la loro farmaco- dinamica risulta essere ancora incompleta. C’è la necessità di incoraggiare di più le industrie farmaceutiche a sviluppare nuovi farmaci specifici per pazienti pediatrici, poiché la sintesi di nuovi farmaci può contribuire alla cura del paziente.
Tuttavia, anche la prevenzione delle malattie è un campo di grande interesse per una crescita della conoscenza in questo settore. Milioni di bambini muoiono a causa di malattie prevedibili, in particolare nei paesi in via di sviluppo.
Negli ultimi anni, la farmacogenomica sta avendo un ruolo fondamentale nei confronti della cura del pazienti, consentendo di avere una medicina personalizzata. Oltre 100 prodotti farmaceutici ora contengono informazioni farmacogenomiche nell’etichetta, e molti di questi sono usati comunemente nella popolazione pediatrica.
Sappiamo come la risposta alla terapia farmacologica è variabile a seconda del paziente e di come gli eventi avversi sono spesso imprevedibili. Ci sono casi in cui il paziente può avere reazioni avverse a dosi basse di uno specifico farmaco rispetto ad altri che invece necessitano di dosi più alte per avere lo stesso effetto terapeutico. La risposta ai farmaci può essere influenzata direttamente da variazioni anche di un singolo gene, e l’utilizzo dei test genetici consentirebbe di predire la probabilità di efficacia, sicurezza o potenziale tossicità, migliorando così le decisioni terapeutiche.
Il farmacista in questo campo ha un ruolo chiave nell’interpretazione clinica dei test farmacogenomici, consentendo l’aggiustamento di dose o la selezione specifica del farmaco in base ai risultati dei test. Si richiede un maggiore coinvolgimento e una maggiore istruzione nel campo della farmacogenomica sia da parte degli studenti
che dei farmacisti per garantire un uso sicuro ed efficace dei farmaci nei pazienti non solo pediatrici, ma che di tutte le età. [132]
Anche se ci sono diverse limitazioni è incoraggiante assistere alla continua crescita della conoscenza sulla farmacoterapia nella popolazione pediatrica, che migliora la qualità della vita di questi piccoli pazienti.
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