ORIGINAL ARTICLE: HEPATOLOGY

Effect of Ursodeoxycholic Acid on Indirect

Hyperbilirubinemia in Neonates Treated
With Phototherapy

Naser Honar, yElham Ghashghaei Saadi, zForough Saki, Narjes Pishva,
y
Nader Shakibazad, and jjSaeed Hosseini Teshnizi

ABSTRACT

Background: Hyperbilirubinemia is a common neonatal problem. The

What Is Known
present study aimed to investigate the effect of ursodeoxycholic acid in
reducing indirect hyperbilirubinemia of infants under phototherapy.  Unconjugated hyperbilirubinemia affects half of the
Methods: This double-blind randomized clinical trial was conducted
full term and almost all of the preterm infants.
on neonates with jaundice, who had received phototherapy in the  Phototherapy is used for unconjugated hyperbiliru-
hospitals affiliated with the Shiraz University of Medical Sciences in
binemia treatment; however, it disrupts mother-child
2013. A total of 80 neonates were enrolled in the study and were
bounding and has potential complications.
randomly divided into 2 groups. The intervention group (n 40) with  Ursodeoxycholic acid is a safe drug used in the
indirect hyperbilirubinemia received 10 mg  kg1  day1 divided every
treatment of cholestatic liver disorders in children,
12 hours Ursobil (capsule 300 mg) in addition to phototherapy, whereas
but it has not yet been studied in neonates.
the control group (n 40) received only phototherapy. Total bilirubin
levels were measured every 12 hours until reaching <10 mg/dL, and then
What Is New
phototherapy was disrupted. The duration of phototherapy was measured.
The 2 groups were compared regarding total bilirubin levels at different  Adding ursodeoxycholic acid to phototherapy in
time points and duration of phototherapy using the generalized
unconjugated hyperbilirubinemia neonates is more
estimating equation (GEE) test.
effective than phototherapy alone in reducing
Results: The mean of total bilirubin in the intervention group was 12  1.6,
serum bilirubin.
10  1.1, and 9.8  0.2 mg/dL 12, 24, and 48 hours after the beginning of  Ursodeoxycholic acid therapy during the first 48
phototherapy, respectively. On the contrary, these measures were 14.4  1.3,
hours of hospitalization decreases the duration of
12.5  1.4, and 10.1  1.1 mg/dL in the control group, respectively,
phototherapy needed for controlling neonatal
(P < 0.05). The mean time required for phototherapy to decrease the
unconjugated hyperbilirubinemia.
bilirubin level to <10 mg/dL was 15.5  6 and 44.6  13.3 hours in the
case and the control group, respectively, (P 0.001).
Conclusions: Ursodeoxycholic acid had additive effect with phototherapy in
neonates with indirect hyperbilirubinemia. This drug also reduced the time Key Words: neonatal indirect hyperbilirubinemia, neonatal jaundice,
period needed for phototherapy and, consequently, decreased the ursodeoxycholic acid
hospitalization period.
(JPGN 2016;62: 97100)

Received December 3, 2014; accepted May 19, 2015.

From the Pediatric Gastroenterology and Hepatology Department, the
yPediatrics Department, the zShiraz Endocrinology and Metabolism
H yperbilirubinemia is a common problem during infancy and
affects half of the full term and almost all of the preterm
infants (1). Typically, phototherapy is used for reducing bilirubin in
Research Center, the Neonatal Research Center, Shiraz University of neonates; however, it has disadvantages, such as being expensive
Medical Sciences, Shiraz, and the jjHormozgan University of Medical and preventing the relationship between the mother and the child
Science, Bandar Abbas, Iran. because of the need for incubator and closure of the infants eyes
Address correspondence and reprint requests to Forough Saki, MD, Shiraz (2,3). Potential complications, such as retinal degenerative changes,
Endocrinology and Metabolism Research Center, Shiraz University of water, and electrolyte disorders, bronze baby syndrome, and ther-
Medical Sciences, PO Box 71345-1744, Shiraz, Iran (e-mail: Sakeif@ mal instability, also threaten such infants. Therefore, using adjuvant
sums.ac.ir). therapies, which reduce the duration of phototherapy and hyperbi-
This article was adapted from Elham Ghashghaei Saadis thesis for special- lirubinemia, can be highly effective (2,3).
ization in pediatrics.
Up to now, several drugs, such as activated charcoal,
This study was supported in part by grant no. 3827 from the research vice-
chancellor of Shiraz University of Medical Sciences, Shiraz, Iran. D-penicillamine, phenobarbital, metalloporphyrin, clofibrate, and
The authors report no conflicts of interest. bile salts, have been used for the treatment of indirect hyperbilir-
Copyright # 2015 by European Society for Pediatric Gastroenterology, ubinemia (47). Several studies have shown phenobarbital to be
Hepatology, and Nutrition and North American Society for Pediatric effective in reducing indirect hyperbilirubinemia and decreasing the
Gastroenterology, Hepatology, and Nutrition duration of phototherapy (8). Nevertheless, it has complications,
DOI: 10.1097/MPG.0000000000000874 including increase in drowsiness, reduction of breast-feeding,

JPGN  Volume 62, Number 1, January 2016 97

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 Saki et al JPGN  Volume 62, Number 1, January 2016

dehydration, and neurological disorders (7). Thus, performing divided q12 h Ursobil (UDCA, capsule 300 mg; provided by Dr
studies on medications with lower complications seems necessary. Abidi Company, Tehran, Iran) that was diluted with water (and was
On the contrary, ursodeoxycholic acid (UDCA) is a bile acid sucked by the babies) according to weight by pharmacist in addition
that is widely used in the treatment of cholestatic liver disorders. It to phototherapy, whereas the control group (n 40) received
protects the liver against oxidative stress, prevents cell apoptosis, placebo (which was water) and phototherapy. Phototherapy was
stimulates the bile flow, and suppresses the confounding factors in performed continuously using daylight fluorescent bulbs (Westing-
immunological mechanisms (9). UDCA is well tolerated and has house, Pittsburgh, PA) in an Air Shields unit (Drager, London, UK).
limited complications in pediatrics (10). The distance between the lamp and the baby was 30 to 35 cm. The
One study, which was conducted on the effect of UDCA duration of phototherapy was measured using a timer. It should be
and phototherapy on unconjugated bilirubin (UCB) in rats, noted that the lamps of the phototherapy device were at a standard
showed that UDCA increased the turnover of UCB by its fecal distance from the patients and were changed after 250 hours. During
disposal (11). phototherapy, genitalia and both eyes of infants were covered.
Owing to the lack of sufficient data about the effect of UDCA On the first day of hospitalization, complete history and
on neonatal unconjugated hyperbilirubinemia, the present study physical examination, total and direct bilirubin, reticulocyte count,
aimed to investigate the effect of UDCA on reducing the UCB of Coombs test, G6PD level, complete blood count, Rh, and blood
the infants undergoing phototherapy, with the hope to reduce the group experiments were performed for both groups. In addition,
lengths of phototherapy and hospitalization. total bilirubin levels were measured by diazo method, every
12 hours until the total bilirubin level reached <10 mg/dL and
phototherapy was disrupted, thereafter total bilirubin levels were
METHODS not checked. (Table 1). All of the information was recorded on a
The present double-blind, randomized clinical trial was data collection form, and the 2 groups were compared regarding
conducted on neonates with jaundice who were treated through total bilirubin levels at different time points, the time duration
phototherapy in the neonatal wards affiliated with the Shiraz in which bilirubin levels reached <10, and the duration of
University of Medical Sciences in 2013. Shiraz is the capital city phototherapy.
of Fars Province, located in the south of Iran. The patients were The study was approved by the ethics committee of the
selected with simple random sampling and were also blindly Shiraz University of Medical Sciences, Shiraz, Iran, and was
divided in groups of case (who were treated with photothera- registered in the Iranian Registry of Clinical Trials (ID:
py UDCA) and control (who were treated with photothera- IRCT2013020512370N1). The parents signed written informed
py placebo) by a single observer (a nurse who blindly treated consent forms.
the neonates with UDCA or placebo and observed the outcome).
Only 1 physician knew the code of neonates who received the
UDCA and did not have any contact with either the parents or the Data Analysis
medical team (including the nurses). Neither the nurse nor the
parents knew which neonate received the UDCA. One statistics All of the data analyses were performed using the SPSS
specialist calculated the sample size using a sample size formula statistical software (SPSS18, IBM SPSS Software, Armonk, NY).
for comparing 2 independent groups (a 0.05, b 0.2, Data were mentioned as mean  SD. Normality of data distribution
d m1m2 0.95, s1 1.5, and s2 1.5); sample size was calcu- was evaluated by Kolmogorov-Smirnov test. Independent sample t
lated as 40 patients for each group. test was used to compare the mean of bilirubin in the 2 groups.
Thus, 40 neonates for the case and 40 neonates for the control Owing to some missing data (those bilirubin which were not
group were enrolled. Statistical power analysis at the end of the checked when the neonate had 1 bilirubin test <10 mg/dL during
study was calculated as 92%, which was greater than power phototherapy), the association between changes of bilirubin over
(1-b 80%). Neonates entered the study after obtaining written time in each group were checked by the generalized estimating
informed consents from their parents. equation (GEE) method with linear link function and unstructured
The inclusion criteria of the study were birth weights of 2500 working correlation matrix. P <0.05 was considered as statistically
to 4000 g, being exclusively breast-fed, gestational age of 38 to 41 significant.
weeks, being >3 days old, total bilirubin level of 14 to 20 mg/dL,
and direct bilirubin level <2 mg/dL. Infants with ABO and RH RESULTS
incompatibility, glucose-6-phosphate dehydrogenase (G6PD) The mean age of the studied subjects was 3.7  1 (36 days)
deficiency, direct hyperbilirubinemia, septicemia, and diseases and 3.6  1 days (37 days) in the intervention and the control
leading to hyperbilirubinemia (Crigler-Najjar syndrome, Gilbert groups, respectively, and no significant difference was found
syndrome, hypothyroidism/hyperthyroidism, liver diseases, etc), between the 2 groups in this regard (P 0.44). Considering sex
premature neonates, and the infants of diabetic mothers were distributions in the intervention group, 21 subjects (52.5%) were
excluded from the study. female, and 19 (47.5%) were male. In the control group, in contrast,
The intervention group, which included 40 infants with 22 (55%) subjects were female. Table 1 summarized the general
unconjugated hyperbilirubinemia, received 10 mg  kg1  day1 characteristics.

TABLE 1. General characteristics of the neonates

Variables Intervention group Control group P

Age 3.7  1 3.6  1 0.44

Sex (female, male) (%) 21 (52.5), 19 (47.5) 22 (55), 18 (45) 0.78
Mean total bilirubin on admission, mg/dL 15.9  1.7 16.3  1.5 0.44
Weight on admission, g 2970  292 2985  312 0.651

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 JPGN  Volume 62, Number 1, January 2016 Ursobils Effect on Neonatal Hyperbilirubinemia

TABLE 2. Comparison of the case and control groups regarding the mean of total bilirubin at different time points after admission

Mean of total bilirubin Case group, mg/dL Standard, mg/dL P 95% Confidence interval

At the time of hospitalization 15.9  1.7 16.3  1.5

12 h after hospitalization 12  1.6 14.4  1.3 <0.001 2.15 to 1.5
24 h after hospitalization 10  1.1 12.5  1.4 <0.001 4.21 to 3.42
48 h after hospitalization 9.8  0.2 10.1  1.1 <0.001 6.89 to 5.84

Total bilirubin was checked and recorded till 10 mg/dL.

The mean of total bilirubin was 16.1  1.6 mg/dL at the time (P < 0.05). In this study, no significant difference was observed
of hospitalization. It was 15.9  1.7 (range 13.220 mg/dL) and between the 2 groups regarding the sex. Most of the study patients
16.3  1.5 mg/dL (range 1420 mg/dL) in the intervention and the were 3 days old (52% in the case and 70% in the control groups).
control groups, respectively, (P 0.44). The mean of total bilirubin This is consistent with other studies conducted on this issue (12).
in the 2 study groups at the time of hospitalization and 12, 24, 48, UDCA is commonly used for the treatment of cholestatic liver
60, and 72 hours after hospitalization is presented in Table 2. The diseases. Previous studies revealed that there were 3 major mech-
results of GEE showed that the bilirubin levels over time within anisms of action for UDCA: first, changes in the composition of
each group were significantly different (P 0.008) (Fig. 1). Gener- mixed phospholipid-rich micelles, reduction of bile acid cytotoxi-
ally, the mean of bilirubin levels over time was significantly less city of bile, and, maybe, reduction of the hydrophobic bile acid
than the control group (P < 0.001). In the intervention group, the concentration in the cholangiocytes could protect cholangiocytes
bilirubin levels had decreased 1.65, 3.82, and 6.37 mg/dL, after 12, against cytotoxicity of hydrophobic bile acids; second, stimulation
24, and 48 hours, respectively. There was no significant association of hepatobiliary secretion, via Ca2-dependent mechanisms and
with age and sex in this regard. protein kinase C-adependent mechanisms may caused insertion of
The mean duration of time required for phototherapy for transporter molecules into the hepatocyte canalicular membrane
decreasing the bilirubin level to <10 mg/dL was 15.5  6 and and, maybe, activation of inserted carriers; third, hepatocytes
44.6  13.3 hours in the case and the control groups, respectively, protection against bile acidinduced apoptosis (13). According
and the difference was statistically significant (P 0.001) (Fig. 2). to the present study results, Ursobil led to an 24-hour reduction
The intervention group was also examined regarding Ursobil in the duration of phototherapy in the neonates suffering from
complications, such as diarrhea and vomiting; however, no com- indirect hyperbilirubinemia most probably by increasing unconju-
plications were detected in any of our patients. gated bilirubin turnover through its fecal disposal (14). The only
study on the effect of UDCA on decreasing UCB is the one
DISCUSSION conducted by Cuperus et al (11) on rats in 2009; the findings of
The results of the present study showed that 12 and 24 hours that study, showed that UDCA increased UCB turnover through
after hospitalization, the mean total bilirubin level had significantly increasing its fecal disposal. Reduction of UCB in the present study
decreased in patients receiving Ursobil and phototherapy compared also seems to result from the same mechanism. Nonetheless,
with those who had only underwent phototherapy (P < 0.05). It Mendez-Sanchez et al (9) investigated the effect of UDCA in rats
seems that the combination of Ursobil and phototherapy leads to a and mice and showed the increase of enterohepatic UCB after the
much more reduction in the total bilirubin levels in comparison with oral consumption of UDCA.
phototherapy alone. No significant difference was found between The findings of the present study showed no short-term
the 2 groups regarding the total bilirubin levels, however, 48 hours complication resulting from Ursobil. Long-term follow-up should
after hospitalization, which shows that the highest effect of
phototherapy accompanied by Ursobil occurs in the first 48 hours 80.0
of hospitalization. Moreover, the mean duration of phototherapy
significantly decreased in the neonates receiving phototherapy and 70.0
Ursobil compared with those who only underwent phototherapy
Phototherapy time, h

60.0

50.0
18
16 40.0
14
30.0
12
10 20.0
Bilirubin

8 Intervention
10.0
6 Control

4 0.0
2
Phototherapy Phototherapy
0 without Ursobil with Ursobil
Baseline 12 h 24 h 48 h
Time Group
FIGURE 2. Duration of phototherapy for the treatment of hyperbilir-
FIGURE 1. Results of GEE analysis of the total bilirubin levels in the ubinemia in both groups (the mean time in the case group was
case and control groups during therapy. GEE generalized estimating 15.5  6 hours and in the control group it was 44.6  13.3 hours).
equation. The difference was statistically significant (P 0.001).

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 Saki et al JPGN  Volume 62, Number 1, January 2016

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