Poractant alfa versus beractant and calfactant in preterm newborns with RDS: a meta-analysis

Surfactant replacement therapy is the standard of care for preterm infants with surfactant deficiency and respiratory distress syndrome (RDS). Beractant, poractant alfa, and calfactant are the three most-commonly used animal-derived surfactants: they differ in their composition (amounts of phospholipids, surfactant-associated proteins SP-B and SP-C, and plasmalogens), viscosity, and volume of administration, which might affect their clinical efficacy and ease of administration.
Beractant is a minced bovine lung extract with added lipids to standardize its composition and to make it similar to other natural lung surfactants. It contains smaller amounts of phospholipids, SP-B, and plasmalogen compared with calfactant, which is a lavage preparation from bovine lung. Poractant alfa is a surfactant derived from minced porcine lungs, subjected to a particular extraction process. As a result, it contains the largest amount of phospholipids distributed in the smallest volumes, as well as the largest amount of plasmalogen.
Many retrospective studies and randomized controlled trials (RCTs) have compared the clinical efficacy of animal-derived surfactants but results are still controversial. On this basis, a group of leading US researchers has conducted a systematic review to compare the efficacy of poractant alfa with that of beractant and calfactant in preterm infants with or at risk of RDS.
In total, five RCTs involving 529 infants compared poractant alfa versus beractant for rescue treatment. No trials studied surfactant prophylaxis, and none compared poractant alfa versus calfactant. The incidences of oxygen dependence at 36 weeks PMA were similar for poractant alfa and beractant. Infants treated with poractant alfa at 100 mg/kg (low dose) or 200 mg/kg (high dose) showed statistically significant reduction in death (relative risk [RR]=0.51; 95% confidence interval [CI]: 0.30–0.89) and need for redosing (RR=0.71; 95% CI: 0.57– 0.88). Statistical analysis revealed that the difference remained statistically significant for high dose poractant alfa but not for low dose poractant alfa (death: RR=0.29; 95% CI: 0.12– 0.66; need for redosing: RR=0.64; 95% CI: 0.53– 0.83). Additionally, significant differences were observed for oxygen requirements, duration of oxygen treatment, and duration of mechanical ventilation, favouring poractant alfa 100 mg/kg over beractant. However, these findings must be interpreted with caution because of significant heterogeneity among studies.
This meta-analysis shows that high-dose poractant alfa may result in superior short-term clinical outcomes, compared with beractant, when used for the treatment of preterm infants with established RDS. In addition, previous cost analyses comparing poractant alfa versus beractant and poractant alfa versus calfactant showed significant cost savings with poractant alfa even when it was used at a dose twice the dose of beractant. Future research should focus on understanding what specific biochemical and biophysical aspects of one surfactant confer superiority over others and should address the issue of outcome advantages with dose-equivalent concentrations of poractant alfa and beractant with a large sample of premature infants at greatest risk.

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