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Transition Protocol of Inhaled Treprostinil to IV Treprostinil in Pulmonary Arterial Hypertension Patient before Surgery

Melisa Wilson


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Conference: 2011 PH Professional Network Symposium

Release Date: 09.22.2011

Presentation Type: Abstracts

M. Wilson, ACNP-BC, MSN, BSN, BSESS and J. Tarver, MD
Orlando Heart Center, Orlando, FL

PURPOSE: Inhaled treprostinil (Tyvaso) is approved for the treatment of pulmonary arterial hypertension (PAH) World Health Organization (WHO) FC III. This is a case report of the protocol used to in a patient requiring transition from Tyvaso to IV treprostinil (Remodulin) due to clinical deterioration and impending surgery.

METHODS: A 56y/o female with Scleroderma associated PAH receiving inhaled treprostinil. 

  • Initially diagnosed in 2003 (PA 68/20/38, CI 2.4) and placed on Tracleer.
  • July 2007, presented with near syncope and significant DOE. Entered clinical trial with Tyvaso. 
  • June 2010 started experiencing dyspnea with minimal exertion. Found to have abdominal mass which was suspicious for cancer; required surgery for bowel resection and removal of mass. 
  • July 2010 RHC performed: PAP 47/15/28, CI 1.55, PVR 888. 
  • Initiation of Remodulin IV was done in the progressive care unit (PCU) in which approximately 60% of the nurses had undergone extensive 6 week course on pulmonary hypertension (PH) WHO groups I-V and only nurses who successfully completed this course can care for patients for PH. Starting dose of IV treprostinil was 2ng/kg/min with rapid up-titration of 2 ng/kg/min every 12 hours while simultaneously down-titrating Tyvaso by 3 breaths daily to off. Vital signs were monitored every 4 hours and PRN. The patient was initially premeditated with Ondansetron. Diphenoxylate/atropine was ordered on an as needed basis for diarrhea.

RESULTS: The transition took place over 8 days with intravenous treprostinil dosing based on improvement in dyspnea, CO, and CI. The patient was transferred to the cardiac intensive care unit (CICU) for hemodynamic monitoring on day 8. The CICU also had nurses who undergone the same training as the PCU nurses and had to meet the same minimum criteria to be able to care for patients with PH and had an additional ICU lecture focusing on hemodynamic changes in patients with PAH. The final dose of IV treprostinil was 17ng/kg/min. The patient experienced hemodynamic improvement as evidenced by increase in CI from 1.55 to 3.8 and resolution of dyspnea. The patient did not need any anti-diarrhea medication and after 2 doses of Ondansetron decline anti-emetic and did not experience nausea or diarrhea.

CONCLUSIONS: This case study describes a protocol that has the ability to quickly and safely transition a progressive PAH patient from inhaled treprostinil to IV treprostinil with improvement in hemodynamics, allowing the patient to successfully undergo abdominal surgery for removal of a colonic mass.

CLINICAL IMPLICATIONS: Regular monitoring of PAH patients allows for detection of stability or deterioration and subsequent therapy change as indicated. Surgical procedures are inherently high risk in patients with PAH, particularly those with poor functional capacity or adverse hemodynamics. The initiation of infused treprostinil, and the rapid up-titration to therapeutic doses based on hemodynamic and clinical factors allowed the successful completion of a necessary surgery in this patient and may serve as a model for patients who face this scenario in the future.

DISCLOSURES: Both Melisa Wilson and James H. Tarver, M.D. are part of the United Therapeutics Speaker Bureau