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Transitioning Prostanoid Therapy in Pulmonary Arterial Hypertension: Aggregate Cohort Data from One Specialty Pharmacy

Lesley D'Albini

Lindy Porco

Janelle Hahn

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Conference: 2018 PHA International PH Conference & Scientific Sessions

Release Date: 06.28.2018

Presentation Type: Abstracts

File Download: Conference 2018_1060

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2018 International PH Conference and Scientific SeAbstract presented at the 2018 International PH Conference and Scientific Sessions in Orlando, Fla., June 28-July 1, 2018.

Background

Prostacyclin therapy has been considered first line for patients with WHO functional class IV pulmonary arterial hypertension (PAH) since the original intravenous epoprostenol formulation was approved by the FDA in 1995. Since then, another twelve novel medications indicated for the treatment of PAH have received regulatory approval, six of which fall into the prostanoid category. Secondary to narrow therapeutic indices and delicate pharmacokinetics, transitions involving prostanoid therapies must be attempted with caution. Particularly problematic are transitions in which both the index drug (from which the patient is weaning) and the target drug (to which the patient is moving) fall into the prostanoid category – epoprostenol (two brands), iloprost, selexipag, or treprostinil (three brands).

Methods

A retrospective cohort analysis of patients transitioning from one prostanoid therapy to another between 01/01/2016 and 12/31/2017 was conducted using the specialty pharmacy electronic medical record. Records were included in the analysis if the primary diagnosis of record was PAH, the patient age fell between 18 and 89 years, and a complete transition detail assessment was performed by a pharmacist. Data collected for each transition included the following: time on the index drug prior to the transition, dose and patient reported side effects of the index drug at the time of transition, and patient reported symptoms of PAH with prescriber adjudicated functional class at the time of transition. Additionally, the presence or absence of background therapy with endothelin receptor antagonists (ETRAs), phosphodiesterase type-5 inhibitors (PDE-5), or a soluble guanylate cyclase stimulator (sGC) either alone or in combination was collected. The time to transition, site of transition and primary reason for the transition were available for a subset of the sample.

Results

1397 prostanoid transitions occurred across 1253 unique patients (144 patients transitioned more than once during the study period). Globally, the majority of patients (985 of 1397; 71%) were on the index prostanoid greater than six months prior to transitioning to an alternate. Patients denied all side effects to the index prostanoid in 60% (839 of 1397) of the transitions. Over half (820 of 1397; 59%) of the patients reported symptoms of PAH at the start of their transition. Thirteen percent of patients transitioned from one prostanoid to another without the benefit of PAH specific background therapy (ETRA/PDE-5/sGC). Prostanoid transition by route of administration is detailed in Figure 1. Statistics around site of, time to, and primary reason for the prostanoid transition varied greatly by route of administration of both the index and target drugs.

Conclusions

There is great variability among prostanoid transitions with respect to route of administration of both the index and target drugs. The majority of patients who transitioned reported symptoms of PAH but denied side effects of the index prostanoid at the time of transition.