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Brash L, Barnes GD, Brewis MJ, Church AC, Gibbs SJ, Howard LSGE, Jayasekera G, Johnson MK, McGlinchey N, Onorato J, Simpson J, Stirrat C, Thomson S, Watson G, Wilkins MR, Xu C, Welsh DJ, Newby DE, Peacock AJ. Short-Term Hemodynamic Effects of Apelin in Patients With Pulmonary Arterial Hypertension. JACC Basic Transl Sci 2018; 3:176-186. [PMID: 29876530 PMCID: PMC5981010 DOI: 10.1016/j.jacbts.2018.01.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/02/2017] [Accepted: 01/13/2018] [Indexed: 11/25/2022]
Abstract
The effects of apelin on pulmonary hemodynamics in patients with PAH are unknown. Systemic infusion caused a significant reduction in pulmonary vascular resistance and increase in cardiac output without a change in heart rate or systemic vascular resistance. This effect was most prominent in the subgroup of patients receiving concomitant PDE5 inhibition. Apelin agonism is a novel potential therapeutic target for PAH.
Apelin agonism causes systemic vasodilatation and increased cardiac contractility in humans, and improves pulmonary arterial hypertension (PAH) in animal models. Here, the authors examined the short-term pulmonary hemodynamic effects of systemic apelin infusion in patients with PAH. In a double-blind randomized crossover study, 19 patients with PAH received intravenous (Pyr1)apelin-13 and matched saline placebo during invasive right heart catheterization. (Pyr1)apelin-13 infusion caused a reduction in pulmonary vascular resistance and increased cardiac output. This effect was accentuated in the subgroup of patients receiving concomitant phosphodiesterase type 5 inhibition. Apelin agonism is a novel potential therapeutic target for PAH. (Effects of Apelin on the Lung Circulation in Pulmonary Hypertension; NCT01457170)
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Affiliation(s)
- Lauren Brash
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Gareth D Barnes
- National Pulmonary Hypertension Service-London, Department of Cardiac Sciences, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Melanie J Brewis
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - A Colin Church
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Simon J Gibbs
- National Pulmonary Hypertension Service-London, Department of Cardiac Sciences, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Luke S G E Howard
- National Pulmonary Hypertension Service-London, Department of Cardiac Sciences, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Geeshath Jayasekera
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Martin K Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Neil McGlinchey
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Joelle Onorato
- Bristol-Myers Squibb Company, Discovery R&D, Princeton, New Jersey
| | - Joanne Simpson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Colin Stirrat
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Stephen Thomson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Geoffrey Watson
- National Pulmonary Hypertension Service-London, Department of Cardiac Sciences, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Martin R Wilkins
- National Pulmonary Hypertension Service-London, Department of Cardiac Sciences, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Carrie Xu
- Bristol-Myers Squibb Company, Discovery R&D, Princeton, New Jersey
| | - David J Welsh
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - David E Newby
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
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Sitbon O, Vonk Noordegraaf A. Epoprostenol and pulmonary arterial hypertension: 20 years of clinical experience. Eur Respir Rev 2017; 26:26/143/160055. [PMID: 28096285 PMCID: PMC9489058 DOI: 10.1183/16000617.0055-2016] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/28/2016] [Indexed: 01/30/2023] Open
Abstract
Epoprostenol was the first therapy to be approved for the treatment of pulmonary arterial hypertension (PAH). In the 20 years since the introduction of this prostacyclin analogue, the outlook for patients with PAH has improved, with survival rates now double those from the era before the development of disease-specific treatments. Today, there are a large amount of data on the clinical role of prostacyclin treatments and a body of evidence attesting the efficacy of epoprostenol in improving exercise capacity, key haemodynamic parameters and PAH symptoms, as well as in reducing mortality. The place of epoprostenol in the therapeutic management of PAH continues to evolve, with the development of new formulations and use in combination with other drug classes. In this review, we provide a historical perspective on the first 20 years of epoprostenol, a therapy that led to evidence-based study of PAH-specific treatments and the subsequent expansion of treatment options for PAH. The evolution of the place of epoprostenol in the management of pulmonary arterial hypertensionhttp://ow.ly/OkY3303N2CX
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Rajagopal K, Hoeper MM. State of the Art: Bridging to lung transplantation using artificial organ support technologies. J Heart Lung Transplant 2016; 35:1385-1398. [PMID: 27916175 DOI: 10.1016/j.healun.2016.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/05/2016] [Accepted: 10/12/2016] [Indexed: 11/29/2022] Open
Abstract
Lung transplantation increasingly is being performed in recipients of higher risk and acuity. A subset of these patients has severely abnormal gas exchange and/or right ventricular dysfunction, such that artificial organ support strategies are required to bridge patients to lung transplantation. We review the rationales and currently used and potential strategies for bridging to lung transplantation and characterize bridging outcomes. Based on physiologic reasoning and a study of the existing literature, we provide a working strategy for bridging to lung transplantation.
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Affiliation(s)
- Keshava Rajagopal
- Center for Advanced Heart Failure and Department of Cardiothoracic/Vascular Surgery, University of Texas-Houston and Memorial Hermann-Texas Medical Center, Houston, Texas.
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, and German Center for Lung Research (DZL), Hannover, Germany
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John J, Palevsky H. Clinical pharmacology and efficacy of inhaled iloprost for the treatment of pulmonary arterial hypertension. Expert Rev Clin Pharmacol 2012; 4:197-205. [PMID: 22115402 DOI: 10.1586/ecp.10.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Similar to other prostanoids, iloprost is a potent vasodilator with considerable antiproliferative and anti-thrombotic properties, although the relevance of its ability to affect platelet aggregation in this subset of patients is unrecognized. The pathogenesis of pulmonary arterial hypertension (PAH) is a multifactorial and complex process secondary to an innate deficiency of substances that induce vasodilation and an overproduction of substances producing vasoconstriction. The production of endothelial vasoactive mediators such as nitric oxide, prostacyclin, endothelin-1, thromboxane and serotonin affect the growth of smooth muscle cells, which facilitate the development of structural remodeling changes that are characteristic of PAH. There have been remarkable advances in understanding the pathologic processes that are responsible for increasing pulmonary vascular resistance and that result in elevated pulmonary artery pressures in order to reverse and prevent progression of the disease process. The goals of treatment in these patients are to alleviate the patients' symptoms, to improve functional capacity and to prevent the progression of the disease. The prostacyclin analogs, such as iloprost, have given hope to these patients who struggle under the burdens of this complex disease.
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Affiliation(s)
- Julie John
- Department of Medicine, Penn Presbyterian Medical Center, 51 N. 39th Street, Philadelphia, PA 19104, USA
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Ewert R, Gläser S, Bollmann T, Schäper C. Inhaled iloprost for therapy in pulmonary arterial hypertension. Expert Rev Respir Med 2011; 5:145-52. [PMID: 21510725 DOI: 10.1586/ers.11.14] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Iloprost (Ventavis, Bayer Schering Pharma, Germany) is a synthetic prostacyclin that is used in its inhalative form for the therapy of pulmonary arterial hypertension. Long-term therapy can increase exercise capacity and quality of life. The use of modern nebulizers especially designed for the administration of iloprost guarantees the pulmonary deposition of the required doses and systematically minimizes side effects. Regarding existing data, inhalative iloprost acts in effective and safe combination with other classes of medication; indeed, such combination therapy is frequently necessary in pulmonary arterial hypertension.
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Affiliation(s)
- Ralf Ewert
- Department of Internal Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany
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Ewert R, Schäper C, Halank M, Gläser S, Opitz CF. Inhalative iloprost – pharmacology and clinical application. Expert Opin Pharmacother 2009; 10:2195-207. [DOI: 10.1517/14656560903164228] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Steven R Kayser
- Department of Clinical Pharmacy, University of California, San Francisco, CA 94143, USA.
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Johnson RF, Loyd JE, Mullican AL, Fink CA, Robbins IM. Long-term follow-up after conversion from intravenous epoprostenol to oral therapy with bosentan or sildenafil in 13 patients with pulmonary arterial hypertension. J Heart Lung Transplant 2007; 26:363-9. [PMID: 17403478 DOI: 10.1016/j.healun.2007.01.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Revised: 11/17/2006] [Accepted: 01/08/2007] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Epoprostenol significantly improves function and survival in patients with pulmonary arterial hypertension (PAH) but is associated with many risks and side effects. Furthermore, effective oral therapy is now available. We report our long-term experience with 13 patients from among 118 treated with epoprostenol who were able to be weaned to oral therapy, including 6 with persistently abnormal hemodynamics (mean pulmonary artery pressure > or = 35 mm Hg). METHODS Oral therapy with bosentan (n = 11) or sildenafil (n =2) was started before weaning epoprostenol in all but 1 patient. Right heart catheterization was performed when patients reached a dose of 2 ng/kg/min, and epoprostenol was discontinued with hemodynamic monitoring. Functional class and 6-minute walk test were assessed at regular intervals. Repeat right heart catheterization was performed 1 year after discontinuation of epoprostenol. RESULTS Nine patients remained on oral therapy alone for up to 46 months. Four patients deteriorated in functional class, and 2 of them resumed epoprostenol therapy. Inhaled iloprost was started in another patient. One additional patient died, unrelated to PAH. Twelve patients underwent right heart catheterization at the time of epoprostenol discontinuation. Hemodynamic evaluation 13.2 +/- 0.9 months later showed that the 5 patients with normal or nearly normal hemodynamics at the time of discontinuation of epoprostenol had no deterioration, whereas 4 of the 7 patients with abnormal hemodynamics had worsened. The 6-minute walk test at last follow-up was not significantly changed from maximal distance on epoprostenol (420 +/- 94 vs 412 +/- 95 meters). CONCLUSION Weaning from epoprostenol to sildenafil or bosentan with sustained clinical improvement is possible, even with persistent pulmonary hypertension; however, patients with persistently abnormal hemodynamics are at risk for hemodynamic and clinical deterioration and require close follow-up.
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Affiliation(s)
- Roger F Johnson
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2650, USA
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Michaels AD, Chatterjee K, De Marco T. Effects of intravenous nesiritide on pulmonary vascular hemodynamics in pulmonary hypertension. J Card Fail 2006; 11:425-31. [PMID: 16105633 DOI: 10.1016/j.cardfail.2005.01.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Revised: 01/24/2005] [Accepted: 01/26/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND Nesiritide is effective in the treatment of decompensated heart failure (HF). We evaluated the acute hemodynamic effects of nesiritide, a recombinant B-type natriuretic peptide, in patients with HF and pulmonary hypertension (PH). METHODS AND RESULTS Twenty patients with HF and PH (mean pulmonary arterial [PA] pressure >25 mm Hg) were enrolled: 10 with postpulmonary capillary wedge (PCW) >15 mm Hg and 10 with precapillary PH (PCW) < or =15. The pulmonary and systemic hemodynamics were determined by right heart catheterization at baseline and at 15 and 30 minutes after an intravenous nesiritide infusion (2 mcg/kg bolus and 0.01 mcg.kg.min). For the patients with postcapillary PH, the mean left ventricular ejection fraction was 28 +/- 15%. After the 30-minute nesiritide infusion, right atrial (RA) pressure decreased 48% (P < .0001), mean PA pressure decreased 29% (P < .0001), PCW pressure decreased 40% (P < .0001), cardiac index (CI) increased 35% (P = .009), pulmonary vascular resistance index (PVRI) decreased 35% (P = .01), and arteriovenous oxygen difference (AVDO(2)) decreased 27% (P = .0003). For precapillary PH patients, there was no change in RA, PA, or PCW pressure, nor any change in CI, PVRI, or AVDO(2). CONCLUSIONS Nesiritide acutely and significantly reduced PA pressure, PVRI, and biventricular filling pressures in patients with postcapillary PH. However, for patients with precapillary PH, nesiritide had no significant acute hemodynamic effect on the pulmonary hemodynamics. The lack of acute beneficial effects of nesiritide in patients with advanced precapillary PH may be related to their relatively fixed remodeling of the pulmonary vasculature.
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Affiliation(s)
- Andrew D Michaels
- Division of Cardiology, Department of Medicine, University of California at San Francisco Medical Center, 94143, USA
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Wonisch M, Fruhwald FM, Maier R, Watzinger N, Hödl R, Kraxner W, Perthold W, Klein WW. Continuous haemodynamic monitoring during exercise in patients with pulmonary hypertension. Int J Cardiol 2005; 101:415-20. [PMID: 15907409 DOI: 10.1016/j.ijcard.2004.03.054] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2003] [Revised: 01/12/2004] [Accepted: 03/05/2004] [Indexed: 02/07/2023]
Abstract
BACKGROUND Right heart haemodynamic parameters can be recorded continuously with the help of an implanted haemodynamic monitor. Aim of the study was to assess the haemodynamic response with and without inhalation of iloprost during cardiopulmonary exercise testing (CPET) in patients with pulmonary hypertension. MATERIALS AND METHODS Five female patients with documented pulmonary hypertension (mean +/- S.D. age 47 +/- 16 years, 4 arterial, 1 venous) previously implanted with a haemodynamic monitor underwent an incremental exercise test on 2 separate days. The tests were performed before and immediately after inhalation of a single dose of iloprost (17 microg). Parameters recorded by the device were right ventricular (RV)-afterload (RV systolic pressure, RVSP), RV-preload (RV diastolic pressure, RVDP), estimated pulmonary artery diastolic pressure (ePAD), heart rate (HR) and maximum positive rate of RV pressure development (RVdP/dt) (reflecting the dynamic and inotropic state of the RV). RESULTS After inhalation of iloprost, RV systolic pressure was always reduced at rest. It was followed by an increase with higher workloads without any difference at VO(2peak). The time course of RV systolic pressure was not linear with a flattening at higher workload during the test. This behaviour was found irrespective of iloprost treatment. The remaining determinants of RV performance showed no relevant differences and a linear behaviour during the exercise test. CONCLUSIONS Inhalation of aerosolised iloprost resulted in a reduction in right ventricular pressure at rest but not at maximal workload. The implantable haemodynamic monitor (IHM) may be useful for the evaluation of RV haemodynamics during exercise and in assessing treatment efficacy.
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Affiliation(s)
- Manfred Wonisch
- Department of Medicine, Division of Cardiology, Medical University, Graz, Austria.
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Saji K, Sakuma M, Suzuki J, Takahashi T, Demachi J, Nawata J, Kitamukai O, Onoue N, Sugimura K, Tada T, Fukui S, Kagaya Y, Watanabe J, Shirato K. Efficacy of acute inhalation of nitric oxide in patients with primary pulmonary hypertension using chronic use of continuous epoprostenol infusion. Circ J 2005; 69:335-8. [PMID: 15731541 DOI: 10.1253/circj.69.335] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There have only been a few reports published on combination therapy for patients with primary pulmonary hypertension (PPH). METHODS AND RESULTS Fifteen patients with PPH (4 men and 11 women, 34.5+/-12.1 years old) had received chronic administration of epoprostenol and the additive effects of inhaled nitric oxide (NO) and the hemodynamic changes were evaluated. In addition, the difference in the effect of acute NO loading before and after the epoprostenol therapy was compared in 6 of these patients. Under chronic use of epoprostenol, mean pulmonary arterial pressure, mean right atrial pressure and pulmonary vascular resistance were decreased with acute inhalation of NO. However, cardiac output, mean aortic pressure and systemic vascular resistance were unchanged. As a result, the pulmonary to systemic vascular resistance ratio was reduced. Moreover, after chronic use of epoprostenol, the change (delta) in cardiac output with NO inhalation was increased and the NO-induced decrease in pulmonary vascular resistance was augmented compared to those before the induction. CONCLUSION Nitric oxide inhalation further improved the hemodynamics when combined with chronic use of epoprostenol in PPH patients. These results suggest the possibility that combination therapies can be used in the treatment for PPH patients.
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Affiliation(s)
- Kenya Saji
- Department of Cardiovascular Medicine, Tohoku University Graduated School of Medicine, Sendai, Japan
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Abstract
OBJECTIVE To review the pharmacology, pharmacodynamics, and clinical trials evaluating inhaled iloprost in pulmonary arterial hypertension (PAH). DATA SOURCES A MEDLINE search (1996–February 2005) was performed using the key words pulmonary hypertension, iloprost, and epoprostenol. Information regarding Food and Drug Administration approval was obtained via the Internet. STUDY SELECTION AND DATA EXTRACTION All clinical trials using inhaled iloprost in PAH published in English were identified. Additionally, references from the identified articles were reviewed. DATA SYNTHESIS A stable analog of prostacyclin, inhaled iloprost is thought to promote benefit in PAH through vasodilation, antiproliferative effects, and inhibition of platelet aggregation. In a placebo-controlled trial of 203 patients, inhaled iloprost significantly improved the combined endpoint of change in New York Heart Association functional class and 10% improvement in 6-minute walk distance (p = 0.007). Small, short-term clinical trials demonstrated hemodynamic benefits for inhaled iloprost alone and in combination with other pulmonary vasodilating agents. The aerosolized delivery route and low incidence of adverse events are positive attributes for inhaled iloprost, while the frequency of administration and lack of comparative data limit its role in PAH. CONCLUSIONS Currently, inhaled iloprost offers potential benefit for patients with contraindications to bosentan, preference for non-parenteral products, ineligibility for parenteral therapy, or as adjunctive therapy with other pulmonary vasodilators. Larger, long-term clinical trials are needed to solidify the role for inhaled iloprost in the management of PAH.
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Affiliation(s)
- Stacey E Baker
- Department of Pharmacy Services, University of Virginia Health System, Charlottesville, VA 22908-0674, USA.
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Abstract
Iloprost is a stable prostacyclin analogue with a pharmacokinetic profile allowing nebulised administration in patients with primary pulmonary hypertension (PPH). Inhaled iloprost is a potent acute pulmonary vasodilator with a duration of action of about 60 minutes. It may exert additional long-term benefit through antiproliferative and antithrombotic effects. Inhaled iloprost 2.5 or 5 microg six or nine times daily for 12 weeks (n = 101) significantly (p < 0.01) improved a combined clinical endpoint of a > or =10% increase in distance walked in 6 minutes and an improvement of > or =1 class in New York Heart Association functional class without clinical deterioration or death (16.8 versus 4.9% of placebo recipients, n = 102) in patients with severe PPH or selected forms of nonprimary pulmonary hypertension. Statistical analysis of the response for the PPH subgroup (20.8 versus 5.5% with placebo; n = 51 and 51) was not reported. Improvements from baseline in exercise capacity and haemodynamic/gas exchange variables have been reported in patients with PPH with continued use of inhaled iloprost. In addition, improvement in preinhalation vascular resistance occurred after 12 weeks of inhaled iloprost (p < 0.01 versus placebo) in a large randomised trial. Increased cough, headache, flushing and an influenza-like syndrome were the most common adverse events in the largest trial of patients receiving inhaled iloprost. Headache, flushing and jaw pain occurred significantly more frequently with inhaled iloprost than with placebo.
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Affiliation(s)
- David R Goldsmith
- Adis International Limited, 41 Centorian Drive, PB 65901, Mairangi Bay, Auckland, New Zealand.
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Stiebellehner L, Petkov V, Vonbank K, Funk G, Schenk P, Ziesche R, Block LH. Long-term treatment with oral sildenafil in addition to continuous IV epoprostenol in patients with pulmonary arterial hypertension. Chest 2003; 123:1293-5. [PMID: 12684325 DOI: 10.1378/chest.123.4.1293] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To evaluate the effect of long-term oral therapy with sildenafil in patients with pulmonary arterial hypertension receiving long-term IV epoprostenol. DESIGN Open, uncontrolled trial. SETTING University hospital. PATIENTS Two patients with primary pulmonary hypertension and one patient with pulmonary arterial hypertension after surgical closure of an atrial septal defect. All patients were receiving continuous epoprostenol for 1.7 to 7.1 years; two patients also received inhaled iloprost for 1.8 years and 3.8 years, respectively. INTERVENTIONS Addition of oral sildenafil, up to 200 mg/d, divided in four to six single doses, and hemodynamic measurements and the 6-min walking distance (6MWD) before and after 5 months of treatment with sildenafil. RESULTS One patient was treated with sildenafil, 200 mg/d; two patients received 75 mg/d due to nausea and headache. Long-term treatment with sildenafil in the three patients reduced mean pulmonary artery pressure by 14%, 41%, and 22%, respectively; in two patients, pulmonary vascular resistance was decreased by 52% and 55%. The 6MWD increased by 34%, 6%, and 29%, respectively. No significant systemic hypotension or decrease of arterial oxygen saturation was seen. CONCLUSION Sildenafil therapy may be of benefit in patients with pulmonary arterial hypertension receiving long-term infusion of epoprostenol.
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Affiliation(s)
- Leopold Stiebellehner
- Department of Internal Medicine IV, Pulmonary Division, University of Vienna, Allgemeines Krankenhaus der Stadt Wien, Austria
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