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Transition from intravenous epoprostenol to oral treprostinil in a patient with pulmonary arterial hypertension

Anirban Bhattacharyya

N Bair

Gustavo Heresi Davila


A. Tonelli

Kristin Highland


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Conference: 2017 PH Professional Network Symposium

Release Date: 10.06.2017

Presentation Type: Abstracts

File Download: 2017 PHPN Abstract 1004

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Abstract presented at the 2017 PH Professional Network Symposium held in Bethesda, MD on October 5-7, 2017

Purpose

To describe an experience of transitioning an epoprostenol patient to oral treprostinil in the ICU setting.

Background

Epoprostenol has improved outcomes including survival in patients with World Health Organization functional Class III and IV pulmonary arterial hypertension (PAH)[1]. However, its short half- life and need for strict monitoring of pump function precludes its use in certain populations. Oral treprostinil monotherapy has been shown to have a modest effect on exercise capacity in patients with WHO functional class II to III symptoms, and there is little experience in patients with more advanced PAH.[2,3]. Although guidelines exist for initiation of oral treprostinil in prostanoid naïve patients, evidence regarding transition from parenteral epoprostenol to oral treprostinil remains limited.

Methods

A 59 year- old female with a long history of idiopathic PAH was electively admitted for management of her PAH medications. She has been treated with intravenous epoprostenol, bosentan and sildenafil for over 10 years with resultant improvement in her functional class and exercise capacity. Prior to this admission, she was diagnosed with Alzheimer’s dementia which was found on several occasions to have made major errors in programming her CADD pump and unable to appropriately respond to pump alarms. It became clear that she was no longer able to safely manage her parental PAH therapy, and a decision was made to transition her to oral treprostinil.

On, admission, her epoprostenol was 60 ng/kg/min, and we estimated that her final dose of oral treprostinil would be 12 mg every 8 hours. Her weight was 50 kg on admission. We used a conversion factor of 1.67 between intravenous epoprostenol and intravenous treprostinil and a correction factor of 5 based on bioavailability of oral treprostinil. [4]. Her intravenous epoprostenol was decreased by 1 ng/kg/min every 2 hours to a maximum of 4 ng/kg/min on the first day followed by 6 ng/kg/min on day 2 and 8 ng/kg/min from the third day on. Oral treprostinil was started at 0.25 mg every 8 hours and up titrated cautiously in the first 3 days to 1.5 mg and from day 4 by 2-3 mg daily. She tolerated this titration well until day 7, when she developed a slight headache. The treprostinil dosage was subsequently increased by only 1 mg on day 7 and 8 to avoid further adverse events. By day 9 she was off her IV epoprostenol and on her goal of 12 mg every 8 hours of oral treprostinil.

Results

Four days into her new oral regimen, she underwent repeat right heart catheterization which showed moderate PAH with a PA mean of 35.3 mm HG, pulmonary vascular resistance of 5 woods units and a thermodilution cardiac index of 3.56 l/min/m2. She was discharged home the following day and continues to live at home with daily assistance.

Conclusion

Certain patients might be candidates for rapid transition from intravenous to oral prostacyclin. Multicenter clinical trials will help in identifying the optimum patient and protocol for the transition.