Patent Ductus Arteriosus (PDA) Medication

  • Author: Luke K Kim, MD; Chief Editor: Stuart Berger, MD   more...
 
Updated: Jan 11, 2012
 

Medication Summary

Medication use in patent ductus arteriosus (PDA) is based upon the clinical status of the patient.

In the presence of symptoms of pulmonary overcirculation or pulmonary hypertension related to a patent ductus arteriosus (PDA), closing the lesion is usually most prudent; therefore, anticongestive therapy is not discussed.

Prostaglandins are utilized to maintain the patency of the ductus arteriosus until surgical ligation is performed. When surgical ligation is not indicated, prostaglandin inhibitors (eg, nonsteroid antiinflammatory drugs [NSAIDs]) are used to close the ductus arteriosus.

Intravenous (IV) indomethacin or IV ibuprofen is used to treat patent ductus arteriosus (PDA) in the neonate and in premature infants. The dose used for ibuprofen is 10 mg/kg bolus followed by 5 mg/kg/d for 2 additional days. (IV ibuprofen became available in the United States on June 2009.)

Ibuprofen was initially thought to have less adverse effects, such as a decreased incidence of oliguria, gastrointestinal (GI) toxicity, and cerebral hypoperfusion. The use of ibuprofen has been shown to increase the incidence of pulmonary hypertension and chronic lung disease.

A Cochrane database review showed no statistically significant difference in closure between ibuprofen and indomethacin.[8] A decision to use one drug versus another should be based upon the infant's presentation and comorbidities.

A similar Cochrane database article that looked at the initial treatment of symptomatic patent ductus arteriosus (PDA) in preterm infants showed no difference in risks or benefits of surgery versus the use of cyclooxygenase inhibitors.[26]

In a prospective, randomized, controlled trial, Attridge et al found that patients administered b-type natriuretic peptide (BNP) received fewer primary indomethacin doses compared with those who were not guided by BNP concentrations.[6] Renal toxicity is associated with indomethacin, and dose reduction guided by BNP may reduce this risk.[6]

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Prostaglandins

Class Summary

Prostaglandins promote vasodilatation by direct effect on the vasculature and smooth muscle of the ductus arteriosus.

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Alprostadil (Prostin VR Pediatric)

 

Alprostadil is used to maintain the patency of the ductus arteriosus when a cyanotic lesion or interrupted aortic arch presents in a newborn. Prostaglandin E1 (PGE1) is most effective in premature infants.

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Nonsteroidal Anti-inflammatory Agents (NSAIDs)

Class Summary

In the neonate, ductal patency appears to be related to continued production of prostaglandin. This is particularly true in the premature infant; therefore, prostaglandin inhibition can affect ductal closure. NSAIDs inhibit the production of prostaglandins by decreasing the activity of cyclooxygenase. The result is a functional closure of the patent ductus arteriosus (PDA) in 80% of patients.

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Ibuprofen lysine injection (NeoProfen)

 

The mechanism of action of ibuprofen lysine injection that results in patent ductus arteriosus (PDA) closure in neonates is not known; however, ibuprofen is an inhibitor of prostaglandin synthesis. This agent is indicated to close a clinically significant PDA in premature infants who weigh between 500-1500 g at ≤ 32 weeks' gestational age when the usual medical management (eg, fluid restriction, diuretics, respiratory support) is ineffective.

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Indomethacin (Indocin)

 

Indomethacin is indicated for patent ductus arteriosus (PDA) closure, as it promotes closure of the PDA and generally has an onset of action within minutes. Prostaglandins, especially E-type prostaglandins, maintain the patency of the ductus. Thus, inhibition of prostaglandin synthesis by indomethacin results in constriction of the ductus arteriosus.

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Contributor Information and Disclosures
Author

Luke K Kim, MD  Fellow, Department of Internal Medicine, Division of Cardiology, New York Presbyterian Hospital, Weill Cornell Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey C Milliken, MD  Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, Southwest Oncology Group, and Western Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD  Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Additional Contributors

Hugh D Allen, MD Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine

Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research

Disclosure: Nothing to disclose.

David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Steven J Compton, MD, FACC, FACP Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Christopher I Doty, MD, FACEP, FAAEM Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Christopher I Doty, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gehaan D'Souza, MD University of California-Irvine School of Medicine

Disclosure: Nothing to disclose.

Justin Galovich, MD Resident Physician, Department of Surgery, University of California, Irvine, School of Medicine

Justin Galovich, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Christopher Johnsrude, MD, MS Chief, Division of Pediatric Cardiology, University of Louisville School of Medicine; Director, Congenital Heart Center, Kosair Children's Hospital

Christopher Johnsrude, MD, MS is a member of the following medical societies: American Academy of Pediatrics and American College of Cardiology

Disclosure: St Jude Medical Honoraria Speaking and teaching

Steven R Neish, MD, SM Director of Pediatric Cardiology Fellowship Program, Associate Professor, Department of Pediatrics, Baylor College of Medicine

Steven R Neish, MD, SM is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Heart Association

Disclosure: Nothing to disclose.

Girish Sethuraman, MD, MPH Assistant Professor, University of Maryland School of Medicine

Girish Sethuraman, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Mark S Slabinski, MD, FACEP, FAAEM Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Park W Willis IV, MD Sarah Graham Distinguished Professor of Medicine and Pediatrics, University of North Carolina at Chapel Hill School of Medicine

Park W Willis IV, MD is a member of the following medical societies: American Society of Echocardiography

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References

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Schematic diagram of a left-to-right shunt of blood flow from the descending aorta via the patent ductus arteriosus (PDA) to the main pulmonary artery.
Diagram illustrating the patent ductus arteriosus.
Diagram illustrating ligation of the patent ductus arteriosus.
Diagram illustrating division and oversewing of the patent ductus arteriosus.
Diagram illustrating patch closure of the patent ductus arteriosus.
 
 
 
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