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Implementation of Epoprostenol Protocol in Outpatient Infusion Center

Elsie Hazelwood

Jennifer Wong

Francesco Boin

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Conference: 2017 PH Professional Network Symposium

Release Date: 10.06.2017

Presentation Type: Abstracts

File Download: 2017 PHPN Abstract 1038

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

Purpose

The purpose of this protocol implementation was to safely utilize epoprostenol in the outpatient setting to improve blood flow for scleroderma (SSc) patients with severe Raynaud’s phenomenon and critical digital ischemia, thereby improving digital ulcers and reducing incidence of digit loss. 

Background

Much of the available literature for outpatient IV prostacyclin use in this patient population has been from Europe, where IV Iloprost is routinely prescribed in SSc subjects to manage vascular as well as fibrotic manifestations. In the US, where IV Iloprost is not available, short term use of IV epoprostenol (Flolan or Veletri) to treat critical digital ischemia has been proposed. Some inpatient experience with use of epoprostenol for this indication has been reported by other institutions. Therefore, we elected to develop and implement our own protocol at UCSF.

Methods

Our Scleroderma team partnered with the Pulmonary Hypertension Nurse Coordinator for this project. A low-dose epoprostenol protocol was created for patients with severe Raynaud’s phenomenon with several safety considerations in place such as: pre-screening of patients to ensure they do not have significant pulmonary hypertension or heart failure and review of recent echo, creating a specific order set in the electronic medical record to ensure standard ordering practices, creation of a SOP (Standard Operating Procedure) for the Infusion Center for this therapy, limiting staff who would care for these patients to a small group, setting pumps with hard stop max dosing to prevent accidental miss-programming of the pump, obtaining approval by several committees including Medication Safety Committee, Pharmacy & Therapeutics Committee, and Patient Safety Committee. Prior to implementing the protocol, hands-on training was completed for a core group of nurses and pharmacists in the Outpatient Infusion Center, and our team was readily available to staff during first few patient infusions for any questions or concerns. In our first 6+ months of infusions, we have had 4 patients receive epoprostenol treatment (2 of the 5 patients have received the treatment twice).

Results

Five patients received treatment in the first 6 months of using the protocol. Overall, the administration of epoprostenol per the UCSF protocol has been tolerated extremely well. No severe adverse advent has been recorded. Findings also include improvement of existing ulcers, shortened healing time (in conjunction with current therapies), and decreased pain.

Conclusion

With appropriate safety measures and implementation of a well-defined infusion protocol, low-dose epoprostenol can be safely administered in the outpatient setting to SSc patients suffering from severe Raynaud’s phenomenon and critical digital ischemia. Our findings to date suggest that this approach is clinically effective and can prevent substantial morbidity from severe peripheral vascular disease in this patient population.