Short versus prolonged indomethacin therapy for patent ductus arteriosus in preterm infants

Indomethacin Use for the Management of Patent Ductus Arteriosus in Preterms: A Web-Based Survey of Practice Attitudes Among Neonatal Fellowship Program Directors in the United States

“…Indomethacin is often used as a first line of treatment for PDA, with reported response rates greater than 60% in premature infants. However, studies have failed to provide conclusive results regarding the optimum duration, specifically short course (three dose) versus prolonged course (more than three doses) of indomethacin therapy [9,20,21,26,32,33,37]. Evidence is insufficient to support or refute the use of multiple courses (two or more courses) of indomethacin for the management of persistent PDA [23].…”

“…In addition, randomized trials conducted to date have varied in their definition of ductal closure based on echocardiographic findings. These variations in echocardiographic definitions of ductal closure have relevance for the interpretation of response rates in the literature and the need for further treatment [10,13,14,20,26,28,32,33,35,37].Although an initial indomethacin course will produce PDA closure in 60-80% of premature infants, the PDA reopens later in 6-53% of infants who initially respond to indomethacin [14,17,22,30]. There also appears to be no consensus regarding the best approach for the management of reopened PDA in premature infants, specifically for a PDA that reopens after the first 2 weeks of postnatal life [25,29].…”

“…There also appears to be no consensus regarding the best approach for the management of reopened PDA in premature infants, specifically for a PDA that reopens after the first 2 weeks of postnatal life [25,29]. The use of indomethacin may also be associated with complications such as renal insufficiency, bleeding diathesis, and focal intestinal perforation [12,21,22,26,31,37]. Therefore, the use of indomethacin is contraindicated if there is oliguria, thrombocytopenia, or renal insufficiency.…”

“…Therefore, the use of indomethacin is contraindicated if there is oliguria, thrombocytopenia, or renal insufficiency. However, there appears to be no uniform criteria for the magnitude of oliguria, the degree of elevated creatinine levels, and the magnitude of thrombocytopenia [10,13,14,20,26,28,32,33,35,37].Institutional practice is expected to be based on existing evidence. If there is strong evidence for a particular treatment plan, one would expect it to be used by most academic medical institutions.…”

“…Earlier studies suggested that a prolonged course of indomethacin therapy may be more effective in producing permanent ductus closure than the standard three-dose course when higher doses of indomethacin (0.2 mg/kg/day) are used with the prolonged course [20,21]. In contrast, recent randomized studies, comparing a short course of indomethacin therapy with a prolonged course using smaller doses (0.1 mg/kg/day), have demonstrated that a prolonged course is no more effective than the standard three-dose short course in producing permanent closure and may in fact be associated with a higher incidence of focal gastrointestinal perforation [21,26,37]. Consistent with these findings, our survey found that most NICUs use a short course (three doses given every 12 hours) of indomethacin therapy rather than a prolonged course.…”