Jump to content


Want to join the discussions?

Sign up for a free membership! 

If you are a member already, log in!

(lost your password? reset it here)

99nicu.org 99nicu.org
  • entries
  • comments
  • views

Paracetamol for the PDA?



EL-Khuffash A, et al. Late medical therapy of patent ductus arteriosus using intravenous paracetamol. Archives of Disease in Childhood - Fetal and Neonatal Edition. 2015;100(3):F253-F6. (CoI statement: The authors of this paper are friends, colleagues and collaborators of mine), the effects of intravenous paracetamol on closing the PDA in infants who were being considered for PDA ligation are reported.

The dose was 60 mg/kg/day in four divided doses. Echos were done after 3 days of treatment and the course continued for a further 3 days if the PDA remained open.

Some of the background includes the fact that the 2 hospitals in Dublin don't give NSAID's during the first week of life, "due to the equivocal nature of the evidence regarding early PDA treatment" and don't give them after 3 weeks "where ibuprofen is not known to be effective" which doesn't give much time to use the 'standard' therapy. So of the 36 babies reported, 13 had never had ibuprofen as they were after 3 weeks, and 15 were said to have contra-indications (11 NEC, 3 IVH, and 1 thrombocytopenia, none of which I am sure are really contra-indications, but let's let that pass for now) only 8 had received ibuprofen (presumably a single course). The pre-paracetamol echo data show physically large PDAs, mean diameter of 3.3 mm, most babies had reverse diastolic flow in the abdominal aorta.

Nine of the babies had closure of their PDA after paracetamol, most of the others had a major constriction, and only 4 needed their PDA ligated in the end.

So if you have a very restricted use of ibuprofen, this is supportive data which shows that if you give IV paracetamol, many babies have closure of the PDA. Of course it doesn't tell you what happens to them if you don't give paracetamol, or if you give them ibuprofen. For that we, of course, need a prospective RCT.

As an aside, intravenous paracetamol is unfortunately unavailable in Canada, I'd really like to be able to give it... but as an analgesic!

  • Upvote 1


Recommended Comments

I don't think there are any large trials published, there are 5 or 6 trials registered, but most are fewer than 200 patients total. 

Arne Ohlsson and Prakesh Shah just published an updated Cochrane review. They were able to include 2 randomized trials, both of oral therapy, and with a total of 250 patients. They showed no real difference in efficacy or in long term outcomes. 

We certainly do need a good trial now, I think there are enough data to support such a trial, if paracetamol works equally well, but maybe has fewer effects of fluid balance (for example) that might lead to better outcomes, if we do the studies right. 

  • Upvote 1
Link to comment

I agree completely, a well-powered comparative trial is def needed.


BTW, I heard from the US-based neonatologist/researcher Matthew Laughton about a planned trial that will be a placebo-controlled evaluation of NSAIDs (i.e. randomization to NSAID or placebo). As the natural course of duct closure (regardless of what's done) is a critical issue that trial will be very interesting (once completed).


However, my personal opinion is that findings from clinical PDA research in general, most commonly including infants around 28-30 weeks, might be difficult to generalize for infants born at 23-25 weekers (i.e. the association between therapy-outcome might be effect-modified by gestational age).

Link to comment

I think you are likely correct, certainly ibuprofen is less effective at earlier gestational ages, and paracetamol might have a different relationship with lower GA. Certainly need to get good studies done. A brand new article since I wrote the above blog post found no effect of paracetamol among VLBW infants who had failed ibuprofen.


(Roofthooft DW, et al. Limited effects of intravenous paracetamol on patent ductus arteriosus in very low birth weight infants with contraindications for ibuprofen or after ibuprofen failure. Eur J Pediatr. 2015:1-8.)

Link to comment

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
  • Create New...