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Navigating Transitions: IV Epoprostenol to oral Treprostinil

Michael Salinero

Tina Hyman

Javier Jimenez

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Conference: 2017 PH Professional Network Symposium

Release Date: 10.06.2017

Presentation Type: Abstracts

File Download: 2017 PHPN Abstract 1018

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

Purpose

At one time IV therapies were the only treatment option indicated for the pulmonary hypertension (PH) patient, today there are alternative medications and routes to choose from. While IV prostacyclins have been proven to be effective in the treatment of severe PH, the central line itself carries risks for infection, line fractures, and are associated with lower quality of life scores due to common side effects including: flushing, sinus congestion, GI discomfort, generalized edema and headaches. This case study details the transition from an IV Epoprostenol to oral Treprostinil over a seven-week period.

Background

Although there have been significant advances in therapies for the treatment of PH, there is a lack of clinical trials to support the transition from IV to oral therapies. The lack of scientific evidence makes transitioning patients from IV drug therapy to oral challenging for most practitioners.

Methods

When establishing the transition, table used in this case study, multiple disciplines were consulted in order to create a safe and comprehensive plan of care including cardiology, pulmonology, pharmacy, nursing, and the pharmaceutical company. Once the oral medication was identified, the clinical pharmacist assembled the transition schedule. Weekly transitions were closely monitored by the cardiologist and the Outpatient Pulmonary Hypertension Clinic staff. The patient’s mental and physical wellbeing was evaluated and documented during the seven week period.

Medication: prostacyclin Total epoprostenol
Week 1
Dose: 0.125mg po TID ( use 1 tab of 0.125mg tabs TID) 0.375mg/day 18ng/kg/min
Week 2 Dose: 0.5mg po TID
(use 2 tablets of 0.25mg tab TID for total of 6 tabs / day) 1.5mg/day 14 ng/kg/min

Week 3
Dose : 1mg po TID
( use 4 tablets of 0.25mg tabs TID for total 12 pills /day) 3mg/day 10ng/kg/min

Week 4
Dose: 2mg po TID
(use 2 tablets of 1mg TID for total of 6 pills/ day) 6mg/day 6ng/kg/min

Week 5
Dose:
morning 3.5mg ( use 2.5mg tab + 1mg tab)
noon 3.0mg ( use 2.5mg tab + 0.5mg tab)
evening 3.5mg (use 2.5mg + 1mg tab ) 10mg/day 3 ng/kg/min

Week 6
Dose:
Morning 4mg (use 2.5mg tab +1mg tab +0.25tab +0.25tab)
noon 4mg (use 2.5mg tab +1mg tab +0.25tab +0.25tab)
evening 4.5mg ( use 2.5mg tab+ 2 tabs of 1mg tabs) 12.5mg/day 1.5ng/kg/min

Week 7
Dose:
morning 4mg (use: 2.5mg tab + 1mg tab +2 tablets of .25mg tab)
noon 5mg ( use: 2 tabs of 2.5mg)
evening 5mg ( use: 2 tabs of 2.5mg ) 14mg/day Stop infusion

Results

The patient was successfully transitioned from IV to oral therapy with no adverse events or decline in functional class. The patient reported having an improved quality of life and was able to resume swimming and other hobbies that had been contraindicated when IV therapy was initiated.

Conclusion

This case study demonstrates that patients meeting certain criteria can safely be transitioned from IV prostacyclins.