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Shlobin OA, Shen E, Wort SJ, Piccari L, Scandurra JA, Hassoun PM, Nikkho SM, Nathan SD. Pulmonary hypertension in the setting of interstitial lung disease: Approach to management and treatment. A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative-Group 3 Pulmonary Hypertension. Pulm Circ 2024; 14:e12310. [PMID: 38205098 PMCID: PMC10777777 DOI: 10.1002/pul2.12310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/09/2023] [Accepted: 11/01/2023] [Indexed: 01/12/2024] Open
Abstract
Pulmonary hypertension (PH) due to interstitial lung disease (ILD), a commonly encountered complication of fibrotic ILDs, is associated with significant morbidity and mortality. Until recently, the studies of pulmonary vasodilator therapy in PH-ILD have been largely disappointing, with some even demonstrating the potential for harm. This paper is part of a series of Consensus Statements from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative for Group 3 Pulmonary Hypertension, with prior publications covering pathogenesis, prevalence, clinical features, phenotyping, clinical trials, and impact of PH-ILD. It offers a comprehensive review of and a holistic approach to treatment of PH-ILD, including the management of underlying interstitial lung diseases, importance of treating the comorbidities, emphasis on importance of exercise and palliation of dyspnea, and review of the most up-to-date guidelines for referral for potential lung transplant work up. It also summarizes the prior, ongoing, and possibly future studies in treatment of the vascular derangement of this morbid condition.
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Affiliation(s)
- Oksana A. Shlobin
- Advanced Lung Disease and Transplant ProgramInova Health SystemFalls ChurchVirginiaUSA
| | - Eric Shen
- United Therapeutics CorporationResearch Triangle ParkNorth CarolinaUSA
| | - Stephen J. Wort
- National Heart and Lung InstituteImperial College LondonLondonUK
| | - Lucilla Piccari
- Department of Pulmonary MedicineHospital del MarBarcelonaSpain
| | | | - Paul M. Hassoun
- Department of Medicine, Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Steven D. Nathan
- Advanced Lung Disease and Transplant ProgramInova Health SystemFalls ChurchVirginiaUSA
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McEvoy C, Argula R, Sahay S, Shapiro S, Eagan C, Hickey AJ, Smutney C, Dillon C, Winkler T, Davis BN, Broderick M, Burger C. Tyvaso DPI: Drug-device characteristics and patient clinical considerations. Pulm Pharmacol Ther 2023; 83:102266. [PMID: 37967762 DOI: 10.1016/j.pupt.2023.102266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/13/2023] [Accepted: 11/06/2023] [Indexed: 11/17/2023]
Abstract
Tyvaso DPI is a drug-device combination therapy comprised of a small, portable, reusable, breath-powered, dry powder inhaler (DPI) for the delivery of treprostinil. It is approved for the treatment of pulmonary arterial hypertension and pulmonary hypertension associated with interstitial lung disease. Tyvaso DPI utilizes single-use prefilled cartridges to ensure proper dosing. Unlike nebulizer devices, administration of Tyvaso DPI is passive and does not require coordination with the device. The low-flow rate design results in targeted delivery to the peripheral lungs due to minimal drug loss from impaction in the oropharynx. The inert fumaryl diketopiperazine (FDKP) excipient forms microparticles that carry treprostinil into the airways, with a high fraction of the particles in the respirable range. In a clinical study in patients with pulmonary arterial hypertension, Tyvaso DPI had similar exposure and pharmacokinetics, low incidence of adverse events, and high patient satisfaction compared with nebulized treprostinil solution. Tyvaso DPI may be considered as a first prostacyclin agent or for those that do not tolerate other prostacyclin formulations, patients with pulmonary comorbidities, patients with mixed Group 1 and Group 3 pulmonary hypertension, or those that prefer an active lifestyle and need a portable, non-invasive treatment. Tyvaso DPI is a patient-preferred, maintenance-free, safe delivery option that may improve patient compliance and adherence.
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Affiliation(s)
- Colleen McEvoy
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Rahul Argula
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Sandeep Sahay
- Division of Pulmonary, Critical Care & Sleep Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Shelley Shapiro
- Cardiology Division, Greater Los Angeles VA Healthcare System, Department of Pulmonary Critical Care, David Geffen UCLA School of Medicine, Los Angeles, CA, USA
| | - Christina Eagan
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, FL, USA
| | | | | | - Chris Dillon
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Thomas Winkler
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | - Brittany N Davis
- United Therapeutics Corporation, Research Triangle Park, NC, USA
| | | | - Charles Burger
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL, USA.
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Bang AA, Bang S, Bang A, Acharya S, Shukla S. Recent Advances in the Treatment of Interstitial Lung Diseases. Cureus 2023; 15:e48016. [PMID: 38034229 PMCID: PMC10687490 DOI: 10.7759/cureus.48016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Interstitial lung diseases (ILDs) are a group of disorders affecting the parenchymal tissue of the lungs. This disease leads to complications like pulmonary hypertension, heart failure, etc. that can affect patients. The etiological factors, clinical features, investigation methods, and diseases are conditions associated with ILD. The history of these conditions is of great value; any history of environmental and occupational exposure, medications, dust, or any toxic inhalation can be a predisposing factor. The CT scan is the investigation of choice in the case of ILD. This article states the recent advances made in treating interstitial lung diseases. The non-pharmacological and pharmacological management of ILD is discussed in the article. The discussion below concerns newer drugs approved by the FDA and their adverse effects, dosages, and contraindications. Below is a detailed conversation about ILD and the recent advances in treating this disease.
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Affiliation(s)
- Aneesh A Bang
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sonali Bang
- Ophthalmology, Sai Rugnalaya Hospital, Umarkhed, IND
| | - Arun Bang
- Orthopaedics, Sai Rugnalaya Hospital, Umarkhed, IND
| | - Sourya Acharya
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Samarth Shukla
- Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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El-Kersh K. Therapy With Inhaled Treprostinil, Macitentan, and Tadalafil/Riociguat in High-Risk Pulmonary Arterial Hypertension. Am J Ther 2023; 30:e499-e502. [PMID: 37713711 DOI: 10.1097/mjt.0000000000001526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Karim El-Kersh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Nebraska Medical Center, Omaha, NE
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El-Kersh K, Jalil BA. Pulmonary hypertension inhaled therapies: An updated review. Am J Med Sci 2023; 366:3-15. [PMID: 36921672 DOI: 10.1016/j.amjms.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
Treatments of pulmonary hypertension (PH) continue to evolve with approval of new therapies. The currently FDA approved inhaled PH therapies include inhaled iloprost for group 1 pulmonary arterial hypertension (PAH), inhaled treprostinil solution and treprostinil dry powder inhaler for both group 1 PAH and group 3 PH associated with interstitial lung disease (PH-ILD). Inhaled treprostinil was recently approved for group 3 PH-ILD based on the results of INCREASE trial and the newer formulation of treprostinil dry powder that comes with a new inhaler was recently approved for both group 1 PAH and group 3 PH-ILD based on BREEZE study. The pipeline for inhaled PH therapies includes several promising molecules that can enrich the current PH therapeutic era and mitigate several systemic side effects by directly delivering the drug to the target organ. In this review article we summarize the evidence for the currently approved inhaled PAH/PH therapies, discuss the available inhalation devices, present a roadmap for successful treatment strategy, and present several inhaled PAH/PH therapies in the pipeline.
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Affiliation(s)
- Karim El-Kersh
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, United States.
| | - Bilal A Jalil
- Assistant Professor of Medicine, Divisions of Cardiovascular Critical Care and Advanced Heart Failure, Heart and Vascular Institute, West Virginia University, Morgantown, WV 26506, United States
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Burger CD, Wu B, Classi P, Morland K. Inhaled treprostinil vs iloprost: Comparison of adherence, persistence, and health care resource utilization in patients with pulmonary arterial hypertension. J Manag Care Spec Pharm 2023; 29:101-108. [PMID: 36580122 PMCID: PMC10387966 DOI: 10.18553/jmcp.2023.29.1.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND: Pulmonary arterial hypertension (PAH) is associated with a substantial clinical and economic burden. Inhaled prostacyclins are a well-established part of pharmacotherapy for PAH. There are differences between inhaled therapies in the burden imposed by administration frequency. Simpler and less time-consuming inhaled PAH therapies may improve both adherence and persistence and potentially affect outcomes. OBJECTIVE: To compare real-world health care resource use, costs, and treatment adherence and persistence in patients with PAH who initiated inhaled treprostinil or iloprost. METHODS: Adult patients with 1 inpatient or 2 outpatient medical claims separated by at least 30 days with a diagnosis of PAH were identified using International Classification of Diseases, Ninth Revision or Tenth Revision, Clinical Modification codes with a pharmacy claim for inhaled treprostinil or iloprost. Patients were required to be continuously enrolled in the health plan for 6 months prior to and 12 months after the index date. A proportion of days covered of 0.8 or more was considered adherent; persistence was no gap in therapy for at least 60 days. All-cause health care resource utilization and all-cause costs were assessed. RESULTS: 405 and 62 patients were included in the inhaled treprostinil and iloprost cohorts, respectively. Adherence (50.9% and 22.6%; P < 0.0001) and persistence (6 months, 65.2% vs 35.5%; 12 months, 46.7% vs 16.1%; log-rank P < 0.001) were significantly better with inhaled treprostinil. Post-index allcause inpatient admissions (39.3% vs 54.8%; P = 0.02) and post-index emergency department (ED) utilization (36.3% vs 50.0%; P = 0.04) were lower with inhaled treprostinil. Among patients who were persistent with therapy through 12 months, there was no significant difference between groups in mean (SD) all-cause total costs ($266,462 [137,324] vs $262,826 [112,452] for inhaled treprostinil vs iloprost, respectively; P = 0.98). CONCLUSIONS: The results suggest that inhaled treprostinil is less burdensome, is associated with greater adherence and persistence, and may reduce all-cause hospitalizations and ED visits. DISCLOSURES: This study was funded by the United Therapeutics Corporation to obtain data for this analysis and compose the manuscript. Dr Burger has served as clinical investigator in multicenter interventional trials sponsored by United Therapeutics but did not receive any direct compensation. Drs Wu and Morland and Mr Classi are employees of United Therapeutics Corporation and own stock/shares in the company.
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Affiliation(s)
| | - Benjamin Wu
- United Therapeutics Corporation, Research Triangle Park, NC
| | - Peter Classi
- United Therapeutics Corporation, Research Triangle Park, NC
| | - Kellie Morland
- United Therapeutics Corporation, Research Triangle Park, NC
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Strategizing Drug Therapies in Pulmonary Hypertension for Improved Outcomes. Pharmaceuticals (Basel) 2022; 15:ph15101242. [PMID: 36297354 PMCID: PMC9609426 DOI: 10.3390/ph15101242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 01/19/2023] Open
Abstract
Pulmonary hypertension (PH) is characterized by a resting mean pulmonary artery pressure (PAP) of 20 mmHg or more and is a disease of multiple etiologies. Of the various types of PH, pulmonary arterial hypertension (PAH) is characterized by elevated resistance in the pulmonary arterial tree. It is a rare but deadly disease characterized by vascular remodeling of the distal pulmonary arteries. This paper focuses on PAH diagnosis and management including current and future treatment options. Over the last 15 years, our understanding of this progressive disease has expanded from the concept of vasoconstrictive/vasodilatory mismatch in the pulmonary arterioles to now a better appreciation of the role of genetic determinants, numerous cell signaling pathways, cell proliferation and apoptosis, fibrosis, thrombosis, and metabolic abnormalities. While knowledge of its pathophysiology has expanded, the majority of the treatments available today still modulate the same three vasodilatory pathways that have been targeted for over 30 years (endothelin, nitric oxide, and prostacyclin). While modifying these pathways may help improve symptoms and quality of life, none of these directly modify the underlying disease pathogenesis. However, there are now studies ongoing with new drugs that can prevent or reverse these underlying causes of PAH. This review discusses the evidence base for the current treatment algorithms for PAH, as well as discusses novel therapies in development.
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