Current evidence on the safety profile of NSAIDs for the treatment of PDA

Early prediction of spontaneous Patent Ductus Arteriosus (PDA) closure and PDA-associated outcomes: a prospective cohort investigation

BACKGROUND

Patent ductus arteriosus (PDA), the most commonly diagnosed cardiovascular condition in preterm infants, is associated with increased mortality and harmful long-term outcomes (chronic lung disease, neurodevelopmental delay). Although pharmacologic and/or interventional treatments to close PDA likely benefit some infants, widespread routine treatment of all preterm infants with PDA may not improve outcomes. Most PDAs close spontaneously by 44-weeks postmenstrual age; treatment is increasingly controversial, varying markedly between institutions and providers. Because treatment detriments may outweigh benefits, especially in infants destined for early, spontaneous PDA closure, the relevant unanswered clinical question is not whether to treat all preterm infants with PDA, but whom to treat (and when). Clinicians cannot currently predict in the first month which infants are at highest risk for persistent PDA, nor which combination of clinical risk factors, echocardiographic measurements, and biomarkers best predict PDA-associated harm.

METHODS

Prospective cohort of untreated infants with PDA (n=450) will be used to predict spontaneous ductal closure timing. Clinical measures, serum (brain natriuretic peptide, N-terminal pro-brain natriuretic peptide) and urine (neutrophil gelatinase-associated lipocalin, heart-type fatty acid-binding protein) biomarkers, and echocardiographic variables collected during each of first 4 postnatal weeks will be analyzed to identify those associated with long-term impairment. Myocardial deformation imaging and tissue Doppler imaging, innovative echocardiographic techniques, will facilitate quantitative evaluation of myocardial performance. Aim1 will estimate probability of spontaneous PDA closure and predict timing of ductal closure using echocardiographic, biomarker, and clinical predictors. Aim2 will specify which echocardiographic predictors and biomarkers are associated with mortality and respiratory illness severity at 36-weeks postmenstrual age. Aim3 will identify which echocardiographic predictors and biomarkers are associated with 22 to 26-month neurodevelopmental delay. Models will be validated in a separate cohort of infants (n=225) enrolled subsequent to primary study cohort.

DISCUSSION

The current study will make significant contributions to scientific knowledge and effective PDA management. Study results will reduce unnecessary and harmful overtreatment of infants with a high probability of early spontaneous PDA closure and facilitate development of outcomes-focused trials to examine effectiveness of PDA closure in "high-risk" infants most likely to receive benefit.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03782610. Registered 20 December 2018.

Catheter-based closure of the patent ductus arteriosus in lower weight infants

Risks associated with drug therapy and surgical ligation have led health care providers to consider alternative strategies for patent ductus arteriosus (PDA) closure. Catheter-based PDA closure is the procedure of choice for ductal closure in adults, children, and infants ≥6kg. Given evidence among older counterparts, interest in catheter-based closure of the PDA in lower weight (<6kg) infants is growing. Among these smaller infants, the goals of this review are to: (1) provide an overview of the procedure; (2) review the types of PDA closure devices; (3) review the technical success (feasibility); (4) review the risks (safety profile); (5) discuss the quality of evidence on procedural efficacy; (6) consider areas for future research. The review provided herein suggests that catheter-based PDA closure is technically feasible, but the lack of comparative trials precludes determination of the optimal strategy for ductal closure in this subgroup of infants.

Nonsteroidal anti-inflammatory administration and patent ductus arteriosus ligation, a survey of practice preferences at US children's hospitals

We surveyed neonatal leadership at 46 US children's hospitals via web-based survey to identify local preferences and concerns regarding indomethacin prophylaxis, nonsteroidal anti-inflammatory drug (NSAID) treatment, and patent ductus arteriosus (PDA) ligation. We received a 100 % survey response (N = 46). Practice guidelines for prophylactic indomethacin were reported at 28 % of NICUs, for NSAID treatment of PDA at 39 % and for surgical ligation at 27 %. Respondents noted intra-institutional practice variation for indomethacin prophylaxis (33 %), NSAID treatment (70 %), and PDA ligation (73 %). The majority of institutions did not prescribe indomethacin prophylaxis (72 %). For PDA treatment, indomethacin was preferred over ibuprofen (80 %). We validated our survey results via comparison with billing data as documented in the Pediatric Health Information System (PHIS) database, finding that survey responses directly correlated with local billing data (p < 0.0001). At institutions that did not typically administer NSAIDs for PDA closure or surgical PDA ligation, a lack of evidence for their effectiveness in improving long-term outcomes and the risk of treatment-associated adverse effects were the most often cited reasons.

CONCLUSION

No consensus exists among providers at US children's hospitals regarding prophylactic indomethacin, NSAID treatment, or PDA ligation. Lack of evidence and safety concerns play a prominent role.

WHAT IS KNOWN

• NSAIDs and surgical PDA ligation are efficacious in preventing intraventricular hemorrhage (IVH) and closing PDA in preterm infants, but have not been shown to improve long-term respiratory, neurodevelopmental, or mortality outcomes. What is New: • Practice preferences for indomethacin prophylaxis, NSAID, and surgical PDA treatment vary both among and within institutions. Lack of treatment effectiveness and the risk of adverse effects are major concerns.

Evidence-based use of indomethacin and ibuprofen in the neonatal intensive care unit

Indomethacin and ibuprofen are potent inhibitors of prostaglandin synthesis. Neonates have been exposed to these compounds for more than 3 decades. Indomethacin is commonly used to prevent intraventricular hemorrhage (IVH), and both drugs are prescribed for the treatment or prevention of patent ductus arteriosus (PDA). This review examines the basis for indomethacin and ibuprofen use in the neonatal intensive care population. Despite the call for restrained use of each drug, the most immature infants are likely to need pharmacologic approaches to reduce high-grade IVH, avoid the need for PDA ligation, and preserve the opportunity for an optimal outcome.