PDA Management in the First Month in High-Risk Preterm Neonate, N/IICU and Inpatient – Pharmacological Treatment

PDA Management in the First Month in High-Risk Preterm Neonate Clinical Pathway — N/IICU and Inpatient

Pharmacological Treatment: Indomethacin, Ibuprofen
or Acetaminophen

Medications for Pharmacologic Closure of the PDA

  • Indomethacin, ibuprofen, or acetaminophen
  • Ibuprofen should not be used for IVH/PDA prophylaxis
  • Acetaminophen can be considered in case of severe renal disease or concern for bowel pathology
  • Weight for dosing
    • During the first 2 weeks postnatally, use birth weight
    • Age > 2 weeks postnatally, use best estimate of dry weight

Potential Contraindications to Indomethacin or Ibuprofen Use

  • Structural heart disease (seek cardiology consult advice)
  • Known or suspected structural renal disease
  • Significant renal impairment (anuria, severe oliguria or serum creatinine > 1.7 and not dropping)
  • Suspected or active necrotizing enterocolitis
  • Thrombocytopenia or coagulation defects
  • Active bleeding

Indomethacin Dosing Schedule – IV Route

  Initial Dose 12 Hours
After Initial Dose 		24-36 Hours
After Initial Dose
< 48 hrs for all weights
or
2-7 days and < 1,250 g		 0.2 mg/kg 0.1 mg/kg 0.1 mg/kg
> 7 days for all weights
or
2-7 days and > 1,250 g		 0.2 mg/kg 0.2 mg/kg 0.2 mg/kg
Most infants should receive the 3rd dose 24 hours after the first dose.
Infants with decreased renal function should receive the 3rd dose 36 hours after the first dose.

Ibuprofen Dosing and Schedule – Oral Route

For alternative routes of administration please refer to your institution’s specific formulary products.

Initial Dose 24 Hours After Initial Dose 48 Hours After Initial Dose
10 mg/kg 5 mg/kg 5 mg/kg
If anuria or marked oliguria (urinary output < 0.6 ml/kg/hr) is evident at the scheduled time of the second or third dose of Ibuprofen, no additional dosage should be administered until laboratory studies indicate that renal function has returned to normal.

Acetaminophen – IV Route

All Gestational and Postnatal Ages 15 mg/kg/dose every 6 hrs x 4-7 days

Please obtain baseline LFTs prior to starting therapy and again on day 4 of therapy. If LFTs are abnormal (> 2-3 time the upper limit of normal) consider discussion with pharmacy, further testing, and/or discontinuing therapy.

Consider repeat echo if neonate stable after 4 days of therapy and consider discontinuing if no change in size of PDA.

Refer to the CHOP Formulary for additional medication information.