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Transition from Parenteral to Inhaled Prostanoid in the Elderly for Palliation

Glenna Traiger


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Conference: 2011 PH Professional Network Symposium

Release Date: 09.22.2011

Presentation Type: Abstracts

Glenna Traiger, RN, MSN, CNS-BC
David Geffen School of Medicine at UCLA, Los Angeles, CA

PURPOSE: With patients living longer on advanced therapies for pulmonary arterial hypertension (PAH), the question of how to manage these complex therapies in elderly patients with few resources must be addressed. It is often very difficult to obtain insurance coverage for parenteral prostanoid therapies when patients are admitted to hospice care or skilled nursing facilities. Transition to inhaled treprostinil may allow these types of patients to continue care at home and remain independent.

BACKGROUND: A significant number of PAH patients are over the age of 65. Almost 17% of patients in the REVEAL Registry were over age 65 at the time of enrollment with mean age at diagnosis of 50.1 yr.1 Patients with connective tissue disease and systemic sclerosis associated PAH were even older with a mean age at the time of diagnosis of 55.51 and 61.82 years respectively. Many patients lose their life partners and do not have or cannot rely on adult children or other family members to assist in their daily care. Parenteral prostanoid therapy is very complex and requires ongoing monitoring of infusion or catheter sites, medication preparation every 1-3 days and pump maintenance. The elderly may develop problems with manual dexterity, memory, and cognition that make it increasingly difficult to manage parenteral therapy independently. In addition, there is limited insurance coverage for this type of in-home care on a daily basis. Due to the structure of US health insurance, it is nearly impossible to obtain coverage for these medications when a patient accesses their hospice benefit or is admitted to a skilled nursing facility, even temporarily. The hospice or skilled nursing facility must pay for all medications out of the per diem payment, making it fiscally unsound for them to accept the patient on expensive prostanoid therapies. If we can simplify the prostanoid therapy, we may allow patients to remain independent in their homes or in independent/assisted living centers longer. These patients generally are less active and may be able to tolerate intermittent prostanoid, which may be an acceptable alternative to discontinuing prostanoid therapy. Treprostinil is now available in inhaled form taken four times daily.

METHODOLOGY: Two cases are presented of elderly women who were treated with subcutaneous treprostinil for >10 years for IPAH. Both patients were experiencing increasing forgetfulness and difficulty manipulating the pumps and infusion components, and maintaining the infusion site. In both cases, a key event forced the decision to change therapy. Case #1 is a 67 yo female with IPAH started on subcu treprostinil in May 2000. Over the years, patient's treprostinil dose was as high as 85 ng/kg/min, but at the time of change to inhaled therapy, subcu treprostinil dose was 48 ng/kg/min with tadalafil 40 mg daily. This patient was off prostanoid for approximately one month due to insurmountable social problems and initiated on inhaled treprostinil Aug. 2010 in an assisted living facility at 3 breaths QID and up-titrated to 9 breaths QID over 1 week. Case #2 is an 85 yo female with IPAH started on subcu treprostinil in Oct. 1999. Subcu treprostinil dose peaked at 70 ng/kg/min in Aug. 2009. Patient had a pump malfunction in Dec. 2009 requiring 2 day hospital admission when subcu treprostinil was restarted at 60 ng/kg/min after a short "bridge" with IV epoprostenol. In Aug 2010 tadalafil 40 mg daily was added and subcu treprostinil dose gradually decreased at home over 2 months to 12 ng/kg/min. Inhaled treprostinil was initiated at home at 3 breaths QID with weekly up-titration of inhaled treprostinil and down-titration of subcu treprostinil until patient was completely transitioned off subcu and on 9 breaths QID of inhaled treprostinil in Dec. 2010.

FINDINGS: Both patients remain stable on inhaled treprostinil with preserved 6 minute walk distance and stable WHO functional class. Case #1 has 6 MWD of 347 m 7 months after the transition and remains in the assisted living facility. She walks to the local YMCA for swim/exercise classes. Case #2 remains at home with her elderly sister but has difficulty maintaining four treatments per day, needing continued reminders to take her treatments. After the transition to inhaled treprostinil, she required pacemaker placement for bradycardia and required adjustment of her back-up rate. At that time, 4 months after the transition, her 6 MWD was 195 m. She has not been seen since the pacemaker rate adjustment. The patient and family express satisfaction with her physical status and are much happier with the less invasive therapy. Updated status of both patients will be presented when available.

IMPLICATIONS: As our PAH population ages, we will be increasingly challenged to maintain complex prostanoid therapy in the home or assisted living setting. Without comprehensive health insurance change, which seems unlikely, these patients will not be able to access long term skilled nursing care or hospice care in conjunction with parenteral prostanoid therapy. Having easier delivery systems, even at the expense of delivering smaller intermittent doses of drug, is a viable option for these patients nearing end of life.

REFERENCES

  1. Badesch DB, Raskob GE, Elliott CG, et al. Pulmonary arterial hypertension: Baseline characteristics from the REVEAL Registry. CHEST 2010;137;376-387.
  2. Chung L, Liu J, Parsons L. et al. Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: Identifying systemic sclerosis as a unique phenotype. CHEST 2010;138;1383-1394.