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Sofer A, Ryan MJ, Tedford RJ, Wirth JA, Fares WH. A systematic review of transition studies of pulmonary arterial hypertension specific medications. Pulm Circ 2017; 7:326-338. [PMID: 28597769 PMCID: PMC5467943 DOI: 10.1177/2045893217706357] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive potentially fatal disease. Multiple pharmacologic options are now available, which facilitated transitions between different therapeutic options, although the evidence for such transitions has not been well described. We sought to review the evidence supporting the safety and/or efficacy of transitioning between PAH-specific medications. We performed a systematic review of all published studies in the Medline database between 1 January 2000 and 30 June 2016 reporting on any transition between the currently Food and Drug Administration (FDA)-approved PAH-specific medications. Studies reporting on three or more adult patients published in the English language reporting on transitions between FDA-approved PAH medications were extracted and tabulated. Forty-one studies met the selection criteria, nine of which included less than eight patients (and thus were reported separately in the supplement), for a total of 32 studies. Transitioning from parenteral epoprostenol to parenteral treprostinil appears to be safe and efficacious in patients who have less severe disease and more favorable hemodynamics. Transitioning from a prostacyclin analogue to an oral medication may be successful in patients who have favorable hemodynamics and stable disease. There is conflicting evidence supporting the transition from a parenteral to an inhaled prostacyclin analogue, even in patients who are on background oral therapy. Currently, the only evidence in support of transitioning between oral PDE5 inhibitors is from sildenafil to tadalafil. Patients on higher doses of sildenafil are more likely to fail. In patients with liver abnormalities due to bosentan or sitaxentan, the transition to ambrisentan appears to be safe and can result in clinical improvement. Studies regarding PAH medication transitions are limited. Patients who have less severe disease, better functional status, and are on lower medications doses may be more successful at transitioning.
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Affiliation(s)
- Avraham Sofer
- 1 Section of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Michael J Ryan
- 2 French Hospital Medical Center, San Luis Obispo, CA, USA
| | - Ryan J Tedford
- 3 Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joel A Wirth
- 4 Tufts University, Boston, MA & Maine Medical Center, Portland, ME, USA
| | - Wassim H Fares
- 1 Section of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
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Ataya A, Somoracki A, Cope J, Alnuaimat H. Transitioning from parenteral to inhaled prostacyclin therapy in pulmonary arterial hypertension. Pulm Pharmacol Ther 2016; 40:39-43. [PMID: 27470680 DOI: 10.1016/j.pupt.2016.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 06/01/2016] [Accepted: 07/22/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Parenteral prostacyclin therapy for PAH has allowed for improvements in functional status, quality of life and mortality. Parenteral therapies however carry an increased risk of line-associated complications. Inhaled prostacyclins are an attractive alternative therapy; however, limited data exists supporting the safety and outcomes after transition. METHODS We describe a retrospective observational analysis of adults with PAH who were transitioned from a parenteral prostacyclin to inhaled treprostinil at our institution. Endpoints include duration of transition, hospital length of stay, adverse effects during transition, and cardiopulmonary function post transition. RESULTS Eight patients were included, all of which were on triple therapy. Seven patients receiving intravenous prostacyclin therapy were transitioned in an ICU setting, while one patient was transitioned from subcutaneous treprostinil as an outpatient. The average ICU and hospital length of stay was 4.1 ± 0.7 days. Patient preference was the most common reason for transition (n = 5), followed by line complication (n = 2), and intolerance to parenteral therapy (n = 1). One adverse event was observed while initiating inhaled treprostinil that only required slowing of the transition process. On follow-up (19.6 ± 11.1 months) functional class did not change, and non-parametric test showed no change in 6MWD after transition (p = 0.62). One patient failed inhaled therapy necessitating transition back to intravenous therapy. CONCLUSION Transitioning patients from parenteral to inhaled prostacyclin therapy can be safely accomplished in specialized centers over a 48-72 h period. Patient preference was overwhelming the most prevalent reason for transition.
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Affiliation(s)
- Ali Ataya
- Pulmonary Vascular Disease Program, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA.
| | - Angelina Somoracki
- Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Jessica Cope
- Department of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Hassan Alnuaimat
- Pulmonary Vascular Disease Program, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
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Sitbon O, Bertoletti L. Connective tissue disease associated with pulmonary arterial hypertension: management of a patient with severe haemodynamic impairment. Eur Respir Rev 2014; 23:505-9. [PMID: 25445949 PMCID: PMC9487410 DOI: 10.1183/09059180.00009214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Pulmonary Arterial Hypertension in Intensive Care Unit. UNCOMMON DISEASES IN THE ICU 2014. [PMCID: PMC7120311 DOI: 10.1007/978-3-319-04576-4_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
For the intensive care unit (ICU) physician, the diagnosis of pulmonary arterial hypertension (PAH) is difficult as it can easily be confounded with other forms of pulmonary hypertension (PH). The key issue is that PAH is a form of PH. On the opposite, PH does not automatically imply PAH. Pulmonary arterial hypertension must be differentiated from other causes of PH that are frequently seen in ICU. It was recently emphasized that pulmonary veno-occlusive disease (PVOD) must be differentiated from PH and PAH. The prognosis of PAH was consistently improved in the ten past years by introduction of selective pulmonary vasodilators and management by highly specialized medical teams. In ICU patients, PAH remains a severe disease with a high mortality rate. When PAH is suspected, a systematic diagnosis approach is of particular importance in order to rapidly eliminate left cardiac, thromboembolic and pulmonary causes of PH. Left cardiac disease is the most common cause of PH. Early recognition of PAH allows a rapid introduction of selective pulmonary vasodilators that can improve outcome. Idiopathic PAH is the most frequent cause but it can also be associated with scleroderma, HIV infection, anorexigen toxicity, thyroid disease, cirrhosis. Pulmonary vasodilators should be only a part of a general management including treatment of triggering factors, optimization of fluid balance, decrease of RV afterload by using pulmonary vasodilators while maintaining cardiac output and mean arterial pressure. The early contact of PH referral center or specialized physician is of particular importance.
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Channick RN, Frantz RP, Kawut SM, Palevsky H, Tumuluri R, Sulica R, Lauto PO, Benton WW, de Boisblanc B. A multicenter, retrospective study of patients with pulmonary arterial hypertension transitioned from parenteral prostacyclin therapy to inhaled iloprost. Pulm Circ 2013; 3:381-8. [PMID: 24015339 PMCID: PMC3757833 DOI: 10.4103/2045-8932.114768] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by progressive increases in pulmonary vascular resistance, leading to right heart failure and death. Guidelines recommend customization of treatment, necessitating the development of effective strategies for transitioning patients among treatments. In this study, we characterized our experience with patient transitions from parenteral prostacyclin to inhaled iloprost. We retrospectively assessed records from 11 centers of 37 consecutive patients with PAH aged ≥ 18 years who were treated with intravenous (IV) or subcutaneous (SC) prostacyclin analogues and transitioned to inhaled iloprost. The transition period began on the first day of inhaled iloprost with the intent of discontinuing parenteral prostacyclin and ended on the first day on inhaled iloprost free of parenteral prostacyclin. Persistence was defined as the absence of (1) parenteral prostacyclin while remaining on inhaled iloprost during post-transition Days 1-90 and (2) no reinitiation of parenteral prostacyclin during post-transition Days 90-365. All patients were clinically stable before transitioning to inhaled iloprost. The mean age was 46.5 years, 70.3% were female, 51.4% had idiopathic PAH, and 43.0% were in New York Heart Association Functional Class III. Among patients with an overlapping transition, the mean transition period was 10.5 days. A transition dosing algorithm was used in 10 patients (27.0%). At one year, 78.4% of the patients remained persistent on inhaled iloprost and 81.1% were free of clinical worsening. In selected patients on background oral PAH therapy, transitioning from parenteral prostacyclin to inhaled iloprost appears safe and feasible and is associated with long-term success. Further study is needed to define the optimal patient selection criteria and transition algorithm.
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Safety and efficacy of transition from systemic prostanoids to inhaled treprostinil in pulmonary arterial hypertension. Am J Cardiol 2012; 110:1546-50. [PMID: 22853986 DOI: 10.1016/j.amjcard.2012.07.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 07/04/2012] [Accepted: 07/04/2012] [Indexed: 11/21/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a disease characterized by increased pulmonary pressures and chronic right heart failure. Therapies for moderate and severe PAH include subcutaneous (SQ) and intravenous (IV) prostanoids that improve symptoms and quality of life. However, treatment compliance can be limited by severe side effects and complications related to methods of drug administration. Inhaled prostanoids, which offer the advantage of direct delivery of the drug to the pulmonary circulation without need for invasive approaches, may serve as an alternative for patients unable to tolerate SQ/IV therapy. In this retrospective cohort study we collected clinical, hemodynamic, and functional data from 18 clinically stable patients with World Health Organization group I PAH seen in 6 large national PAH centers before and after transitioning to inhaled treprostinil from IV/SQ prostanoids. Before transition 15 patients had been receiving IV or SQ treprostinil (mean dose 73 ng/kg/min) and 3 patients had been on IV epoprostenol (mean dose 10 ng/kg/min) for an average duration of 113 ± 80 months. Although most patients who transitioned to inhaled treprostinil demonstrated no statistically significant worsening of hemodynamics or 6-minute walk distance, a minority demonstrated worsening of New York Heart Association functional class over a 7-month period. In conclusion, although transition of patients from IV/SQ prostanoids to inhaled treprostinil appears to be well tolerated in clinically stable patients, they should remain closely monitored for signs of clinical decompensation.
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Fox B, Langleben D, Hirsch AM, Schlesinger RD, Eisenberg MJ, Joyal D, Blenkhorn F, Lesenko L. Hemodynamic stability after transitioning between endothelin receptor antagonists in patients with pulmonary arterial hypertension. Can J Cardiol 2012; 29:672-7. [PMID: 22819360 DOI: 10.1016/j.cjca.2012.05.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 05/09/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Maintenance of a favourable hemodynamic profile is central to therapeutic success in pulmonary arterial hypertension (PAH). There is little information about the safety of transitioning patients between oral therapies for PAH. Endothelin receptor antagonists (ERAs) have been a therapeutic mainstay in PAH, providing benefit to many patients. Three ERAs, bosentan, sitaxsentan, and ambrisentan have been approved for clinical use. Sitaxsentan was voluntarily withdrawn from the market in late 2010 resulting in the need to quickly transition a large number of stable patients. METHODS We transitioned 30 clinically stable patients to either ambrisentan or bosentan. Patients underwent a right heart catheterization, measurement of serum N-terminal pro-brain natriuretic peptide (NT-proBNP), and assessment of functional class before changing ERA and again 4 months later. We present a retrospective analysis of those data. RESULTS Of the 30 patients transitioned (15 to ambrisentan, 15 to bosentan), 23 had complete hemodynamic data. No significant change was observed in the groups in right atrial, mean pulmonary artery, and pulmonary artery wedge pressures, or in cardiac output, pulmonary vascular resistance, or NT-proBNP levels. There was no change in World Health Organization functional class. Four ambrisentan and 2 bosentan-treated patients reported fluid retention, and 3 bosentan-treated patients had elevation of hepatic transaminases. Two of the patients had a right atrial pressure increase of ≥5 mm Hg, and 4 had pulmonary artery wedge pressure increase of ≥5 mm Hg. CONCLUSIONS Transitioning between ERAs in stable PAH patients does not result in hemodynamic or clinical deterioration during the first 4 months posttransition. A minority of patients have developed increased cardiac filling pressures.
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Affiliation(s)
- Benjamin Fox
- Center for Pulmonary Vascular Disease, Jewish General Hospital and McGill University, Montreal, Québec, Canada
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Abstract
Pulmonary hypertension (PH) is a severe, life-threatening disease for which there are no effective curative therapies. A diverse group of agents such as prostacyclins, endothelin antagonists, phosphodiesterase inhibitors, calcium channel blockers, diuretics, inotropic agents, and anticoagulants are used to treat PH; however, none of these agents have a marked effect upon survival. Among the new agents that promise treatment of PH are rho-kinase inhibitors and soluble guanylate cyclase stimulators. Although these new classes of agents have beneficial effects in experimental animal models and clinical studies, they are not selective in their actions on the pulmonary vascular bed. This manuscript reviews the actions of rho-kinase inhibitors and soluble guanylate cyclase stimulators on the pulmonary vascular bed. It is our hypothesis that these new agents may be more effective than current therapies in the treatment of PH. Moreover, new methods in the delivery of these agents to the lung need to be developed so that their main effects will be exerted in the pulmonary vascular bed and their systemic effects can be minimized or avoided.
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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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Krug S, Sablotzki A, Hammerschmidt S, Wirtz H, Seyfarth HJ. Inhaled iloprost for the control of pulmonary hypertension. Vasc Health Risk Manag 2009; 5:465-74. [PMID: 19475782 PMCID: PMC2686263 DOI: 10.2147/vhrm.s3223] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening disease characterized by an elevated pulmonary arterial pressure and vascular resistance with a poor prognosis. Various pulmonary and extrapulmonary causes are now recognized to exist separately from the idiopathic form of pulmonary hypertension. An imbalance in the presence of vasoconstrictors and vasodilators plays an important role in the pathophysiology of the disease, one example being the lack of prostacyclin. Prostacyclin and its analogues are potent vasodilators with antithrombotic, antiproliferative and anti-inflammatory qualities, all of which are important factors in the pathogenesis of precapillary pulmonary hypertension. Iloprost is a stable prostacyclin analogue available for intravenous and aerosolized application. Due to the severe side effects of intravenous administration, the use of inhaled iloprost has become a mainstay in PAH therapy. However, owing to the necessity for 6 to 9 inhalations a day, oral treatment is often preferred as a first-line therapy. Numerous studies proving the efficacy and safety of inhaled iloprost have been performed. It is therefore available for a first-line therapy for PAH. The combination with endothelin-receptor antagonists or sildenafil has shown encouraging effects. Further studies with larger patient populations will have to demonstrate the use of combination therapy for long-term treatment of pulmonary hypertension.
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Affiliation(s)
- Sabine Krug
- Department of Respiratory Medicine, University of Leipzig, Leipzig, Germany.
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Reddy MT, Patel H, Ventura HO. Successful Transition From Intravenous to Inhaled Prostacyclin in a Patient With Pulmonary Hypertension and Right Ventricular Failure. ACTA ACUST UNITED AC 2008; 14:285-6. [DOI: 10.1111/j.1751-7133.2008.00006.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stiefel MF, Zaghloul KA, Bloom S, Gracias VH, LeRoux PD. Improved cerebral oxygenation after high-dose inhaled aerosolized prostacyclin therapy for acute lung injury: a case report. THE JOURNAL OF TRAUMA 2007; 63:1155-1158. [PMID: 17993965 DOI: 10.1097/ta.0b013e31815965e3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Michael F Stiefel
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19107, USA
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Moro JA, Almenar L, Morales P, Osa A. Efecto rebote tras la inhalación de prostaciclina en hipertensión pulmonar. Med Clin (Barc) 2007; 129:279. [PMID: 17683713 DOI: 10.1157/13108358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Park SY, Moon DH, Park YB, Na JO, Whang HK, Lim BS, Lee SD. Perfusion lung scan as a prognostic indicator of response to beraprost sodium in idiopathic pulmonary arterial hypertension. Pulm Pharmacol Ther 2006; 19:264-71. [PMID: 16139536 DOI: 10.1016/j.pupt.2005.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2004] [Revised: 05/15/2005] [Accepted: 06/28/2005] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE To study whether there is any difference in the clinical characteristics between the two patterns of perfusion lung scan of idiopathic pulmonary arterial hypertension (normal vs. diffuse, multiple ill-defined defects) and whether the perfusion lung scan patterns of these patients would predict the effect of long-term use of beraprost sodium. METHODS We evaluated 27 patients who used beraprost sodium for over 3 months, and noted a diffuse patchy pattern in 13 cases and a normal pattern in the remaining 14 cases. We judged that beraprost sodium was effective when at least two of the following conditions were met: improvement in symptom of dyspnea, more than 10% decrease in peak velocity of tricuspid valve regurgitation by echocardiography (Vmax), or more than 10% increase in 6-min walking distance. RESULTS At baseline there was no difference between the two groups in dyspnea, hemodynamic parameters, and 6-min walking distance. After the use of beraprost sodium, the normal group showed improvement in dyspnea, 6-min walking distance, and Vmax. But the diffuse patchy group showed no improvement. The use of beraprost sodium in the normal group was effective in 10 out of 14 cases, but was effective in only two out of 13 cases in the diffuse patchy group. CONCLUSION Perfusion lung scan pattern in patients with idiopathic pulmonary arterial hypertension is a useful prognostic indicator of the response to beraprost sodium.
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Affiliation(s)
- So-Yeon Park
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul 138-736, South Korea
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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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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
During the last decade we have witnessed substantial improvements in the therapeutic options for pulmonary arterial hypertension (PAH), including true innovations targeting some of the mechanisms involved in the pathogenesis of this devastating disease. Intravenous epoprostenol was the first drug to improve symptoms and survival of patients with PAH. Novel prostanoids, including subcutaneous treprostinil and inhaled iloprost, also have beneficial effects in many patients, although their long-term efficacy is less well known. Among the newer treatments for PAH, endothelin receptor antagonists and phosphodiesterase type 5 (PDE5) inhibitors have reshaped clinical practice. The endothelin receptor antagonist bosentan has been approved in many parts of the world and most current guidelines recommend this drug as first-line treatment for patients with PAH in functional class III. Novel endothelin receptor antagonists such as sitaxsentan sodium and ambrisentan are currently being investigated. The PDE5 sildenafil is also being intensively studied in patients with pulmonary hypertension, and most of the available data look promising, although approval for PAH is still pending. Other PDE5 inhibitors have not yet undergone extensive study in PAH. The increasing insight into the pathogenesis of PAH opens several new therapeutic opportunities, which include vasoactive intestinal peptide, selective serotonin reuptake inhibitors, adrenomedullin and HMG-CoA reductase inhibitors (statins). However, PAH is a complex disorder and targeting a single pathway can not be expected to be uniformly successful. Thus, combining substances with different modes of action is expected to improve symptoms, haemodynamics and survival in PAH patients, although combination therapy has yet to undergo the scrutiny of large randomised clinical trials.
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Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
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García Hernández FJ, Ocaña Medina C, Mateos Romero L, Martínez Martínez A, Bautista Lorite A, Santos Ramos B, Sánchez Román J. Tratamiento combinado con prostaciclina intravenosa y sildenafilo en pacientes con hipertensión arterial pulmonar: descripción de 4 casos. Med Clin (Barc) 2004; 122:64-6. [PMID: 14733859 DOI: 10.1016/s0025-7753(04)74143-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Here we report the experience obtained from a combined treatment with intravenous (i.v) prostacyclin and oral sildenafil in patients with severe pulmonary hypertension (PHT) who had a poor response to prior treatment with prostacyclin alone. PATIENTS AND METHOD Sildenafil was added to the treatment in four patients with PHT (primary in two patients and secondary to collagenosis in the other two) with no adequate response to i.v. prostacyclin treatment. The clinical course, 6minutes walking test and echocardiogram were evaluated. RESULTS Initial sildenafil dose was 12.5 mg three times daily, which was increased up to 50 mg three times daily in one patient and up to 50 mg four times daily in the other three. The symptoms of right heart failure were controlled in all cases. Before the start of sildenafil administration, two patients had class III dyspnea and two patients had class IV dyspnea. Two patients converted to class I (previously class III and IV), and the other two converted to class II. The distance walked within 6 minutes increased (average increase 55%) and systolic pulmonary artery pressure decreased in all patients (average reduction 27%). Effects of sildenafil were substained. The only side effect seen was mild headache. CONCLUSIONS Our experience supports the value of sildenafil in the treatment of PHT and suggests that combined treatment is useful for rescuing patients who fail to respond to initial treatment with i.v. prostacyclin.
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Kramm T, Eberle B, Krummenauer F, Guth S, Oelert H, Mayer E. Inhaled iloprost in patients with chronic thromboembolic pulmonary hypertension: effects before and after pulmonary thromboendarterectomy. Ann Thorac Surg 2003; 76:711-8. [PMID: 12963183 DOI: 10.1016/s0003-4975(03)00728-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND In primary pulmonary hypertension, aerosolized prostanoids selectively reduce pulmonary vascular resistance and improve right ventricular function. In this study, hemodynamic effects of inhaled iloprost, a stable prostacyclin analogue, were evaluated in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and early after pulmonary thromboendarterctomy (PTE). METHODS Ten patients (mean age 49 years old [32 to 70 years old], New York Heart Association functional class III and IV) received a dose of 33 micro g aerosolized iloprost immediately before surgery (T1), after intensive care unit admission (T2), and 12-hours postoperatively (T3). Effects on pulmonary and systemic hemodynamics and gas exchange were recorded and compared with preinhalation baseline values. RESULTS Preoperatively, inhaled iloprost did not significantly change mean pulmonary artery pressure (mPAP), cardiac index (CI), or pulmonary vascular resistance (PVR). Postoperatively, inhaled iloprost induced a significant reduction of mPAP and PVR and a significant increase of CI at T2 and T3. Preinhalation versus postinhalation PVR was as follows: at T1, 847 versus 729 dynes. s. cm(-5), p = 0.45; at T2, 502 versus 316 dynes. s. cm(-5), p = 0.008; and at T3, 299 versus 227 dynes. s. cm(-5), p = 0.004. CONCLUSIONS In patients with CTEPH, inhalation of iloprost elicits no significant pulmonary vasodilation before surgery, and may have detrimental effects on systemic hemodynamics. Postoperatively, it significantly reduces mPAP and PVR, and enhances CI. Following PTE, inhalation of iloprost is useful to improve early postoperative hemodynamics.
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Affiliation(s)
- Thorsten Kramm
- Departments of Cardiothoracic and Vascular Surgery, Mainz, Germany.
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Fruhwald FM, Kjellström B, Perthold W, Watzinger N, Maier R, Grandjean PA, Klein W. Continuous hemodynamic monitoring in pulmonary hypertensive patients treated with inhaled iloprost. Chest 2003; 124:351-9. [PMID: 12853544 DOI: 10.1378/chest.124.1.351] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Aerosolized iloprost is used as an alternative to IV prostacyclin in patients with pulmonary hypertension. The desired outcome of this treatment is a reduction of pulmonary pressure, which can be measured by right-heart catheterization or Doppler echocardiography. However, both techniques provide only snapshots of the hemodynamic state. PATIENTS AND METHODS The aim of our study was to test the usability of an implantable hemodynamic monitor (IHM) [the Chronicle, model 9520; Medtronic Inc; Minneapolis, MN] in patients with pulmonary hypertension. For this purpose, the device was implanted into five patients (mean [+/- SEM] age, 45 +/- 16 years; all women) with pulmonary hypertension who had received long-term treatment with aerosolized iloprost (100 micro g/d). Repeated short-term tests including two standard inhalations of iloprost as well as repeated long-term tests lasting 20 to 26 h, including nighttime, without inhalation were performed on an outpatient basis. RESULTS The device provided information that was reproducible and individual for each patient during the entire study period. During short-term tests, pulmonary artery pressure was reduced from a mean (of all patients) of 68 +/- 13 to 49 +/- 11 mm Hg, with a mean total effective treatment time of 49 +/- 8 min. Thereafter, pulmonary pressure returned to preinhalation levels before the next inhalation. Long-term tests showed similar results. During a total recorded time of 15,876 min, the vasodilator effect lasted 2,140 min, corresponding to 13% of the whole time span. CONCLUSION Our study provided new insights into the short-term and long-term effects of treatment with inhaled iloprost in patients with pulmonary hypertension. While there were no signs of tachyphylaxis, the improvement of central hemodynamics was much shorter than expected. Continuous hemodynamic monitoring with the IHM demonstrated the need to improve the treatment modalities of aerosolized iloprost in patients with pulmonary hypertension.
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Affiliation(s)
- Friedrich M Fruhwald
- Department of Medicine, Division of Cardiology, Karl-Franzens University, Graz, Austria.
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Kemming G, Habler O, Kleen M, Kisch-Wedel H, Welte M, Zwissler B. Searching the ideal inhaled vasodilator: from nitric oxide to prostacyclin. Eur Surg Res 2002; 34:196-202. [PMID: 11867923 DOI: 10.1159/000048909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Today, the technique to directly administer vasodilators via the airway to treat pulmonary hypertension and to improve pulmonary gas exchange is widely accepted among clinicians. The flood of scientific work focussing on this new therapeutic concept had been initiated by a fundamental new observation by Pepke-Zaba [1]and Frostell in 1991 [2]: Both scientists reported, that inhalation of exogenous nitric oxide (NO) gas selectively dilates pulmonary vessels without a concomittant systemic vasodilation. No more than another decade ago NO was identified as an important endogenous vasodilator [3]while having merely been regarded an environmental pollutant before that time. Although inhaled NO proved to be efficacious, alternatives were sought-after due to NO's potential side-effects. In search for the ideal inhaled vasodilator another group of endogenous mediators -- the prostanoids -- came into the focus of interest. The evidence for safety and efficacy of inhaled prostanoids is -- among a lot of other valuable work -- based on a series of experimental and clinical investigations that have been performed or designed at the Institute for Surgical Research under the guidance and mentorship of Prof. Dr. med. Dr. h.c. mult. K. Messmer [4-19]. In the following, the current and newly emerging clinical applications of inhaled prostanoids and the experimental data which they are based on, will be reviewed.
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Affiliation(s)
- G Kemming
- Institute for Surgical Research, Clinic of Anesthesiology, Ludwig Maximilians University Munich, Germany
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